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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/sajoussanalytic02sajo 


SAJOUS'S 

Analytical  Cyclop/Edia 

OF 

Practical  Medicine 

BT 

CHARLES  E.  de  M.  SAJOUS  M.D. 


ONE  HUNDRED   ASSOCIATE   EDITORS 

ASSISTED  BY 

CORRESPONDING  EDITORS  COLLABORATORS 
AND  CORRESPONDENTS 


Illustrated  witb  CbromO'Cithograpbs  engriivings  ana  maps 


Third    Revised.    Edition 


VOLUlxrEl   II 


PHILAnELPHIA 

F.   A.  DAVIS  COMPANY  PUBLISHERS 
1905 


COPYRIGHT,  1905, 

BY 

F.  A.  DAVIS  COMPANY. 
I  Registered  at  Stationers'  Hall,  London,  Eng.| 


Philadelphia,  Pa.,  U.S.  A.: 

The  Medical  Bulletin  Prlntlng-houM, 

I'JlUfl  Cherry  Street. 


Sou  2. 


PREFACE. 

The  majority  of  the  sections  included  in  the  first  volume,  as  stated  in  the 
preface  of  the  latter,  were  prepared  under  the  immediate  supervision  of  the  editor 
and  submitted  to  the  various  members  of  the  associate  staff  for  revision  and  cor- 
rection. Each  associate  enjoying  the  privilege  of  erasing,  changing,  and  adding 
anything  he  chose,  the  correctness  of  the  views  advanced  was  insured,  while  the 
innovations  as  to  form  introduced  by  the  editor  could  satisfactorily  be  carried  into 
effect.  The  second  volume  inaugurates  the  regular  plan  of  the  work  as  regards 
elaboration:  all  the  articles  have  been  prepared  by  their  respective  editors,  and 
the  result  shows  the  kind  interest  taken  in  the  work  by  all  the  members  of  the 
staff,  to  whom  the  editor  extends  expressions  of  sincere  gratitude. 

The  aim  of  the  editor  is  not  only  to  facilitate  the  labor  of  the  practicing 
physician  and  to  assist  investigators  and  authors  in  their  researches,  but  he  also 
seeks  to  elucidate,  through  contributions  from  men  possessing  special  knowledge 
or  unusual  experience  in  a  particular  line,  diseases  which,  owing  to  their  com- 
plexity, arc  not  generally  understood.  This  plan  has  borne  fruit,  and  the  readers 
will  have  before  them,  in  this  volume,  exceptionally-valuable  articles  on  a  num- 
ber of  exacting  subjects,  namely:  "Cerebral  Hremorrhage,"  by  Dr.  William 
Browning,  of  Brooklyn;  "Cirrhosis  of  the  Liver,"  by  Professor  Adami,  of 
Montreal;  "Cholera,"  by  Professor  Eubino,  of  Naples;  "Cholelithiasis."  by  Pro- 
fessor Graham,  of  Toronto;  "Diabetes,"  by  Professor  Lepine,  of  Lyons,  etc.  The 
better-known  affections  have  also  been  edited  by  writers  of  special  ability. 
Among  the  articles  of  this  kind  is  that  on  "Diphtheria,"  by  Drs.  Northrup  and 
Bovaird,  of  New  York,  who  contribute  a  masterly  review  of  our  present 
knowledge  of  this  affection  from  every  stand-point.  The  papers  by  Professor 
Bondurant,  of  Mobile,  on  "Chorea";  Dr.  Norman  Kerr,  of  London,  on  "Cocaiuo- 
mania";  Dr.  Oliver,  of  Philadelphia,  on  "Cataract";  Prof.  Nathan  S.  Davis, 
of  Chicago,  on  "Constipation";  Dr.  Vickerj-,  of  Boston,  on  "Dilatation  of  the 
Heart,"  are,  among  others,  particularly  entitled  to  the  readers'  special  attention. 
An  infirmity  but  little  studied  by  the  general  practitioner  is  "Deaf-mutism." 
A  section  giving  an  exhaustive  review  of  the  subject  has  been  contributed  by 
Dr.  Holger  Mygind,  of  Copenhagen,  one  of  the  greatest  living  authorities  upon 
the  pathogenesis  of  this  condition. 

(iii) 


JT  PREFACE. 

Eepeated  inquiries  having  reached  the  central  department  as  regards  the 
authorship  of  the  fifty-page  article  on  "Animal  Extracts"  which  appeared  in 
the  first  volume,  the  editor  wishes  to  state  that  he  wrote  it  himself,  and  that 
he  fully  appreciates  the  kind  expressions  relating  thereto,  and  also  the  many 
encouraging  reviews  which  the  medical  press  has  accorded  the  first  volume. 

The  Editok. 
2043  Walnut  Street. 


STAFF  OF  ASSOCIATE  EDITORS. 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,   P.   Q. 


ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 


LEWIS  H.  ABLER,  M.D., 

PHILADELPHIA,    PA. 


ERNEST  W.  GUSHING,  M.D., 

BOSTON,  MASS. 


JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA,    PA. 


GWILYil  G.  DA\aS,  II.D., 

PHILADELPHIA,   PA. 


THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA,   PA. 


N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL. 


A.  D.  BLACIvADER,  M.D., 

MONTRE.\L,  P.   Q. 


E.  D.  BONDURANT,  M.D., 

MOBILE,   ALA. 


AUGUSTUS  A.  ESHNER,  JI.D., 

PHILADELPHIA,    PA. 


SIMON  FLEXNER,  M.D., 

PHIL.iDELPHIA,   PA. 


DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITY. 


LEONARD  FREE.\L\N,  M.D., 

DENVER,  COL. 


WILLIAM  BROAVNING,  M.D., 

BROOKLYN,  N.   Y. 


S.  G.  GANT,  M.D., 

NEW  YORK  CITY. 


WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 


J.  :McFADDEN  GASTON,  M.JJ., 

ATLANTA,   GA. 


CHARLES  W.  BURR,  M.U., 

PHILADELPHIA,    PA. 


HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 


HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA,   PA. 


J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 


E.  B.  GLEASON,  M.D., 

PHILADELPHIA,   PA. 


EGBERT  H.  GRANDIN.  .M.D.. 

NEW  YORK  CITY. 


WILLIAM  B.  COLEY,  M.D., 

NEW  YORK  CITY. 


J.  P.  CROZER  GRIFFITH,  .M.D.. 

PHILADELPHIA,    PA. 


FLOYD  ;m.  crandall,  M.n., 

NEW  YORK  CITY. 


C.  M.  HAY,  M.D.. 

nULADELPniA,    P.V. 


(V) 


STAFF  OF  ASSOCIATE  EDITORS. 


FREDERICK  P.  HEXRY,  M.D., 

PHIT.AnELPHIA,   PA. 

L.  EM3JETT  HOLT,  il.D., 

JvEW  TOKK  CITY. 

EDWARD  JACKSOX,  M.D., 

DEXVEK,  COL. 

W.  W.  IvEEN,  M.D., 

PHILADELPHIA,    PA. 

EDWARD  L.  KEYES,  Jk.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  laRBY,  M.D., 

PHILADELPHIA,    PA. 

L.  E.  LA  FETRA,  M.D., 

XEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA,   PA. 

E.  LEPINE,  M.D., 

LYONS,  FRANCE. 

F.  LEVISON,  M.U., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  JL^RLOW,  M.D., 

SYRACUSE,  N.  Y. 

SIMON  MARX,  M.D., 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  M.D., 

TORONTO,    ONT. 

E.  E.  MONTGOMERY,  M.D., 

I'lIILADEI.PHIA,    PA. 

IIOLOER  MYGIND,  M.L., 

COPENHAGEN,  DENMARK. 


W.  p.  NORTHRUP,  M.D., 

NEW  YORK  CITY. 

RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  C. 

H.  OBERSTEINER,  M.D., 

VIENNA,   AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELnnA,    PA. 

WILLIAM  OSLER,  M.D., 

BALTIMORE,   MD. 

LEWIS  S.  PILCHER,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAJI  CAMPBELL  POSEY,  M.D., 

PHILADELPHIA,   PA. 

W.  B.  PRITCHARD,  M.D., 

NEW  YORK  CITY'. 

•JAMES  J.  PUTNAM,  M.D., 

BOSTON,   MASS. 

B.  ALEXANDER  RANDALL,  M.D., 

PHILADELPHIA,    PA. 

CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITY. 

ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 

REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY^. 

JACOB  E.  SCHADLE,  M.D., 

ST.   PAUL,   MINN. 

.JOHN  B.  SHOBER,  M.D., 

I'JIILADELPIIIA,    PA. 

J.  SOLIS-COHEN,  M.D., 

I'HILADF.T.PHIA,    PA. 

SOLO.MON  SOLIS-COIIEN,  M.D., 

I'HILADKI.I'IIIA,    PA. 


STAFF  OF  ASSOCIATE  EDITORS. 


H.  W.  STELWAGOK,  M.U., 

PHILADELPHIA,    PA. 


HERMAN  F.  ^'ICKERV,  M.D., 

BOSTOX,   MA§S. 


D.  D.  STE\VART,  M.D., 

rniLADELPHLA,    PA. 


LEWIS  A.  STIMSON,  M.D., 

NEW  TOKK  CITY. 


J.  EDWARD  STUBBERT,  M.D., 

LIBERTY,  N.   Y. 


A.  E.  TAYLOR,  M.D., 

SAN  FBANCISCO,  CAL. 


J.  MADISON  TAYLOR,  Ji.U., 

PHILADELPHIA,    PA. 


M.  B.  TINKER,  M.D., 

PHILADELPHIA.    PA. 


F.  E.  WAXHAM,  il.D., 

DEXTER,  COL. 


J.  WILLIAM  WHITE,  M.D., 

PHILADELPHIA,    PA. 


.JAMES  C.  WILSON,  M.D , 

PHILADELPHIA,    PA. 


C.  SUMNER  WITHERSTINE,  M.D., 

PHILADELPHIA,    PA. 


ALFRED  C.  \\00D,  M.U., 

PHILADELPHIA,    PA. 


CHARLES  S.  TURNBULL,  M.D., 

PHILADELPHIA.    PA. 


WALTER  WYi\L\N,  M.D., 

WASHINGTON,  D.  C. 


TABLE  OF  CONTENTS. 


(Volum    II.) 


PAGE 

A.  C.  E.  Mixture 88 

Amoebic  Dysentery 590,  595 

Ankle,  Dislocation  of 587 

Antitoxin  in  Diphtheria 551 

Anus,  Stricture  of 310 

Arterial  Cirrhosis 236 

Asiatic  Cholera 134 

Astragalus,  Dislocation  of 587 

Biliary  Cirrhosis 228 

Blood-vessels,  Injuries  of,  due  to  Disloca- 
tions    577 

Brain,  Hernia  of 691 

Burns  of  Conjunctiva 308 

Burns  of  Cornea 331 

Caffeine 266 

Caffeine  Poisoning 267 

Carpal  Bones,  Dislocation  of 580 

Carpo-metacarpal,  Dislocation  of 580 

Cataract  1 

Catarrhal  Conjunctivitis  279 

Catarrhal  Croup  352 

Catarrhal  Dysentery   588,  601 

Centrilobar  Cinhosis 237 

Cerebral  Abscess 20 

Cerebral  Hemorrhage 31 

Cerebral  Hernia   691 

Cerebral  Paralysis,  Infantile 675 

Cerium    52 

Cervical  Vertebra,  Dislocation  of 569 

Chaulmugra-oil 53 

Chloral  Derivatives  and  Compounds 54 

Chloral  Poisoning   62 

Chloralamid 59 

Chloralose    59 

Chlorctone    61 

Chloroform    65 

Chloroform  Poisoning 76 

Chlorosis 89 

Cholecystenterostomy  127 

Cholccystotoniy    128 

Choledochotomy  131 


PAGB 

Cholelithiasis 104 

Cholera  Asiatica 134 

Cholera  Infantum 155 

Cholera  Morbus  162 

Cholera  Nostras 162 

Choluria   167 

Chorea ITO 

Chromic  Acid   185 

Chrysarobin 186 

Chyluria  187 

Cimicifuga    191 

Cimicifuga  Poisoning   192 

Cinchona,  Derivatives  and  Compounds.  . .   193 

Cinchona  Poisoning 199 

Cinnamon  and  Derivatives 202 

Cirrhosis,  Gliasonian 237 

Cirrhosis  of  Liver 204 

Clavicle,  Dislocation  of 570 

Clitoritis 241 

Coca 243 

Cocaine  243 

Cocaine  Poisoning  244 

Cocainoniania,  or  Cocaine  Habit 256 

Coccyx,  Dislocation  of 5S2 

Cochin  China  DiaiThcea 600 

Coffee  and  Caffeine 264 

Coffee  Poisoning 265 

Colchicum 269 

Colocynth 275 

Colocynth  Poisoning 276 

Conjunctiva,  Diseases  of 277 

Conjunctivitis   279 

Constipation    309 

Convallaria  Majalis 318 

Copaiba 319 

Copaiba  Poisoning 321 

Copper 322 

Copper  Salts,  Poisoning 325 

Cornea,  Disorders  of 330 

Corn-ergot  and  Corn-silk 339 

Costal  Cartilages,  Dislocation  of 570 

Cotton-plant    339 

Creasote  and  Preparations 341 

Creasote  Poisoning  344 


TABLE  OF  CONTENTS. 


PAQB 

Croup    352 

Croupous  Conjunctivitis 300 

Cubeb    359 

Curara 360 

Curara  Poisoning 362 

Cystitis  ■. 363 

Deaf-mutism    373 

Dermatitis   404 

Diabetes  Insipidus 423 

Diabetes  Mellitus 427 

Diarrhoea  Alba   (see  Cholera  Infantum). 

Diarrhoea,  Cochin  China 600 

Diarrhoea,   Infantile    (see   Infantile   Diar- 
rhoea and  Cholera  Infantum). 

Digitalis   466 

Digitalis  Poisoning  475 

Dilatation  of  Heart 483 

Diphtheria 497 

Diphtheritic  Conjunctivitis  303 

Diphtheritic  Dysentery  589,  604 

Dislocations 562 

Dysentery 587 

Dysmenorrhoea   Oil 

Eclampsia 622 

Eczema    635 

ElTusions,  Pulsating  Pleural 673 

Egyptian  Ophthalmia 291 

Elaterium  and  Elaterin 651 

Elaterium  Poisoning 652 

Elbow,  Dislocation  of 577,  580 

Elephantiasis 652 

Empyema,  Thoracic 659 

Empyema,  Tubercular 673 

Encephalitis 674 

Encephalocele    691 

Endometritis   696 

Ensifomi  Process,  Dislocation  of 570 

Fibula,  Dislocation  of 586 

Fingers,  Dislocation  of 581 

Follicular  Conjunctivitis 282 

Foreign  Bodies  in  Conjunctiva 308 

Foreign  Bodies  in  Cornea 331 

Olissonian  Cirrhosis   237 

GlosBO-labio-laryngeal  Paralysis 077 

Oonorrbf/'al  Ophthalmia 285 

OoHsypiuni  Horbaceuni 339 

Granular  Conjunctivitis 291 

Heart,  Dilatation  of 483 

Hernia  Cerebri   091 


PAOB 

Hip,  Dislocation  of 5S2 

Huntingdon's  Chorea   185 

Hydrencephalocele  691 

Hypnal    61 

Injuries   of   Conjunctiva 308 

Interlobar  Pleurisy  671 

Jaw,  Dislocation  of 569 

Knee,  Dislocation  of 585 

Laryngeal  Diphtheria 507 

Lordosis   070 

Lupus  of  Conjunctiva 304 

Lymphatic  Conjunctivitis  299 

Membranous  Croup 356 

Meningocele  691 

Meningo-encephalitis,  Chronic   687 

Metatarsus,  Dislocation  of 587 

Miliary  Ophthalmia 291 

Nasal  Diphtheria  500 

Nerves,  Injuries  due  to  Dislocations 577 

Occiput,  Dislocation  of 569 

Oculomotor  Palsy   GS5 

Opacities  of  Cornea  333 

Ophthalmia,  Egyptian   291 

Ophthalmia,  Gonorrhoea!  235 

Ophthalmia,  Miliary  291 

Ophthalmia  Neonatorum 288 

Paget's  Disease 417 

Paracentesis  Thoracis 066 

Paralysis,  Bulbar 675 

Paralysis,  Crossed  37 

Paralysis,  General,  of  Insane 088 

Paralysis,  Infantile,  Cerebral 075 

Paralysis  of  Uculomotor  Nerve 085 

Patella,  Dislocation  of 580 

Pediculosis  642 

Pelvis,  Dislocation  of 582 

Pemphigus  of  Conjunctiva 305 

Pericellular  Cirrhosis   234 

Pharyngeal  Diphtheria  501 

Phlyctenular  Conjunctivitis   299 

Pleural   Effusions,  Pulsating 673 

Pleurisy,  Intei'lobar 071 

Poisoning,  Caffeine   207 

I'oisoniiig,  Chloral   62 

Poisoning,  Chloroform 70 

Poisoning,  Cimicifuga  192 


TABLE  OF  CONTEXTS. 


Poisoning,  Cinchona  199 

Poisoning,  Cocaine 244 

Poisoning,  Coffee  205 

Poisoning,  Colocynth   276 

Poisoning,  Copaiba  321 

Poisoning,  Copper  Salts  325 

Poisoning,  Creasote  344 

Poisoning,  Curara   362 

Poisoning,  Digitalis 475 

Poisoning,  Elaterium    652 

Polioencephalitis,  Inferior 677 

Polyuria   423 

Portal  Cirrhosis  207 

Pterygium    307 

Purpura    199 

Purulent  Conjunctivitis  284 

Pyothorax    663 

Quinetura   197 

Quinic  Acid  198 

Quinidine    197 

Quinoidine    198 

Quinoline    198 

Quinolinic  Acid 198 

Quinopicrie  Acid 198 

Quinovic  Acid  198 

Radio-ulnar  Joint,  Dislocations  of 5S0 

Radius,  Dislocation  of 579 

Ribs,  Dislocation  of 570 


Septic  Diphtheria  505 

Shoulder,  Dislocation  of 572 

Skyphosis 670 

Spine,  Dislocation  of 509 

Sporadic  Cirrhosis  239 

Sternum,  Dislocation  of 570 

Stigmata  Maydis  339 

Stricture,  Anal  310 

Strumous  Conjunctivitis   299 

Subacromial  Dislocations 572 

Subastragaloid  Dislocation  587 

Sydenham's  Chorea  170 

Syphilitic  Diseases  of  Conjunctiva 305 

Tarsus,  Dislocation  of 587 

Thoracic  Empyema  659 

Thumb,  Dislocation  of 581 

Tic  Co-ordin6 184 

Tonsillar  Diphtheria  501 

Trachoma  291 

Tubercular  Diseases  ot  Conjunctiva 304 

Tubercular  Empyema  073 

Tumors  of  Conjunctiva 305 

Tumors  of  Cornea 333 

Ulna,  Dislocation  of 579 

Urine,  Bloody,  in  Cystitis 303 

Ustilago  Maydis 339 

Vernal  Conjunctivil.s 283 

Vertebrce,  Dislocation  of  Lower  Cervical. .  509 

Secondary  Cirrhosis 237   . 

Semilunar  Cartilages,  Dislocation  of 585   |  Zuckerguss  Leber 237 


SAJOUS'S 

Analytical  Cyclopedia  of  Practical 

Medicine. 


CATARACT.— Gr.,xaTapaxT>;s;  from 
xarapdaaaiv,  to  fall  down. 

Definition. — By  the  term  "cataract" 
is  meant  an  opacity,  partial  or  complete, 
of  the  crystalline  lens. 

Varieties. — The  opacity  of  the  crystal- 
line lens  may  be  (a)  primary  or  idio- 
pathic, (b)  secondary  to  diseases  of  other 
ocular  structures,  and  (c)  symptomatic  of 
other  disorders. 

Symptoms. — The  objective  symptoms 
vary  according  to  the  variety  of  the 
cataract,  being  mainly  dependent  upon 
the  extent,  the  character,  and  the  density 
of  the  lenticular  opacity. 

In  the  immature  forms  the  anterior 
chambers  may  be  shallower  than  normal, 
this  being  due  to  a  forward  protrusion 
of  the  iris,  produced  by  a  swelling  of  the 
lens.  In  hypermature  cataract  the  ante- 
rior chamber  may  become  deep,  while  in 
tlie  mature  condition  it  is  practically  of 
normal  size. 

The  mere  inspection  of  the  pupil  with- 
out the  aid  of  oblique  illumination  does 
not  always  give  conclusive  evidence  in 
regard  to  the  presence  of  cataract;  yet, 
generally,  especially  in  fairly-advanced 
eases,  the  pupillary  area  appears  dull 
gray  or  glistening  white,  according  to 
the  character,  the  condition,  and  the  age 
of  the  lenticular  opacity;    a  condition, 

2- 


however,  that  needs  careful  clinical  con- 
firmation before  any  certainty  as  to  diag- 
nosis can  be  vouchsafed.  At  times  the 
pupil  may  appear  almost  entirely  black 
or  brown  in  tint.  In  some,  particularly 
indeterminate  cases  of  this  type,  the 
catoptric  test  is  of  value.  Very  rarely, 
glistening  polychromous,  crystalline 
masses  may  stud  the  pupillary  area. 

Study  of  the  eye-ground  in  the  in- 
cipient stages  will  frequently,  especially 
in  comparatively  young  and  ametropic 
subjects,  reveal  coarse  local  changes  con- 
nected with  the  uveal  tract.  In  all  cases, 
except  when  contra-indicated,  and  in  all 
stages,  mydriatics  should  be  resorted  to, 
to  make  as  thorough  a  study  of  the  in- 
tra-ocular  conditions  as  possible.  Vision 
is  always  disturbed  to  a  greater  or  less 
degree,  according  to  the  situation,  the 
extent,  and  the  nature  of  the  opacity. 

Exniiiination,  with  Dr.  Rogers,  of 
records  of  Inst  250  cases  of  cataract  of 
nil  forms  seen  jointly  in  tlie  Inst  three 
years,  nnd,  excluding  juvenile,  lamellar, 
nnd  traumatic  cataract.  Forty-six  found 
nnionsr  patients  still  young  enough  to 
have  active  ciliary  muscles.  Thirty- 
seven  of  these  had  prnotically  normal 
vision,  ranging  from  5-6  to  5-5.  when 
their  refraction  errors  were  corrected, 
nnd  almost  all  came  complnining  of  as- 
thenopia rnther  than  of  dimness  of  vision. 
A  minute  exnmination  bv  means  of  ob- 


CATAEACT.    SYMPTOMS. 


lique  illumination  revealed  small  clouded 
areas  in  the  peripheral  layers,,  sometimes 
few  in  number  and  sometimes  numerous, 
or  minute  points  of  opacity  scattered 
throughout  the  lens-substance  in  such  a 
manner  as  to  make  it  seem  incredible 
that  in  spite  of  this  obstruction  the  pa- 
tient had  vision  of  5-5 — or  average  nor- 
mal acuity.  C.  F.  Clark  (Columbus  Med. 
Jour.,  July  19,  '98). 

Attention    called    to    error    frequently 
made  in  hasty  diagnosis  of  senile  cataract 
by   general   practitioners,   who  misinter- 
pret the  reflection  of  light  by  transparent 
lenses  in  elderly  persons,  and  particularly 
in  those  belonging  to  the  African  races. 
The  gray  color  of  the  pupil  is  often  mis- 
leading, and  may  influence  the  physician 
to  express  his  opinion  that  cataract  is 
present,  when  further  examination  with 
oblique    light    and    with    the    ophthal- 
moscope will  convince  him  that  his  diag- 
nosis is  erroneous.    Hansell  (Phila.  Poly- 
clinic;   Georgia  Jour,  of  Med.  and  Surg., 
Sept.,  '98). 
The  subjective  signs  are  fairly  con- 
stant in  all  forms  of  cataract.     Large, 
circumscribed,  peripherally-seated  opaci- 
ties are  much  less  destructive  to  sight 
than  small  ones,  or  even  faint  nuclear 
haze  situated  opposite  the  pupillary  area. 
Nearly    always    during    the    formative 
period,  motes,   "veils,"   and   "cobwebs" 
are  spoken  of,  while  at  times  multiple 
and  distorted  vision  is  the  chief  com- 
plaint.     As    the    lens    becomes    more 
opaque,  however,  the  sight  becomes  more 
and  more  reduced,  until,  eventually,  any 
large  objects  can  no  longer  be  discerned, 
although   if   the   condition   be   uncom- 
plicated, the  distinction  between  light 
and  darkness  remains. 

During  the  incipient  stages  of  cataract 
it  frequently  happens  in  the  aged  that 
they  are  able  to  dispense  with  lenses  or- 
dinarily used  for  near-work,  and  at  times 
require  concave  ones  for  distant  vision. 
This,  which  is  due  to  an  increase  in  the 
refractive  power  of  the  eye,  consequent 
upon  swelling  of  the  lens,  before  any 


opacity  makes  its  appearance,  is  known 
as  '"second  sight."  Pain  and  photo- 
phobia, which  are  best  relieved  by 
smoked  glasses,  are  rather  infrequent 
symptoms  in  the  early  stages,  and  are 
referable  to  the  pressure  of  the  swelled 
lens  on  the  ciliary  body  and  iris. 

As  already  stated,  there  are  three 
varieties  of  cataract:  (a)  primary  or 
idiopathic,  (&)  secondary  to  diseases  of 
other  ocular  structures,  and  (c)  sympto- 
matic of  some  systemic  disturbance. 

In  two  of  three  eases  which  had  been 
struck  by  lightning  cataract  developed 
in  both  eyes  two  days  later.     Both  pa- 
tients, one  a  boy  of  13  and  his  brother 
11  years  old,  had  been  unconscious,  the 
former  for  a  short  time,  tlie  younger  for 
two  days.     Linear  extraction  was  per- 
formed in   both,  with   success.     In   the 
third  case,  a  man  of  24,  unconsciousness 
had  lasted  ten  minutes  only.    Some  time 
later  a  cataract  developed  in  the  right 
eye.    Extraction  with  iridectomy  proved 
successful.    Comparatively  few  cases  of 
cataract   due   to   lightning-stroke   have 
been    described    in    literature.      Joseph 
Preindlsberger     {Wiener     klin.     Woch.. 
Mar.  28,  1901). 
A  cataract  may  remain  permanently 
limited  to  some  particular  portion  of  the 
lens,  or  it  may  gradually  involve  the  en- 
tire lens-substance  and  lead  to  complete 
opacification. 

The  former  variety,  which  is  divided 
into  several  types,  dependent  upon  the 
locality  of  the  lens  involved,  may  be 
either  congenital  or  acquired.  When  the 
opacity  is  situated  in  the  anterior  pole 
of  the  lens,  the  condition  is  known  as 
anterior  polar  cataract  or  anterior  py- 
ramidal cataract.  The  cause  of  the  con- 
genital form  is  supposed  to  be  due  to 
some  foetal  disturbance  operating  dur- 
ing the  development  of  the  lens.  In  the 
polar  variety,  which,  in  reality,  is  one 
of  the  true  cataractous  forms,  the  opacity 
assumes  the  figure  of  a  star  or  rosette, 
with  its  radii  extending  toward  the  pe- 


CATARACT.    SYMPTOMS. 


riphery.  It  has  been  seen  to  follow  con- 
tusions of  the  globe,  to  appear  as  a  part 
of  pigmentary  retinitis,  and  exliibit  it- 
self as  a  consequence  of  uveitis.  The 
post-natal  form,  as  a  rule,  is  the  per- 
manent result  of  rupture  of  a  corneal 
ulcer,  by  which  the  anterior  capsule  of 
the  lens  is  brought  into  contact  with  the 
inflamed   cornea,   leading   to   prolifera- 


Capaular  cataract.     {Becker.) 


tion  of  the  epithelial  cells  of  the  lens 
occupying  the  position  of  the  pupillary 
area,  with  the  formation  of  a  subcapsular 
opacity  after  tlie  reformation  of  the 
anterior  chamber;  this  being  in  addi- 
tion to  the  nebule,  which,  as  a  rule,  but 
faintly  marks  the  site  of  the  previous 
corneal  ulceration.  When,  in  addition, 
there  is  a  deposition  upon  the  anterior 
face  of  the  capsule  which  in  itself  is 
irregular,  opaque,  and  thickened  di- 
rectly beneath,  the  condition  is  known 
as  anterior  pyramidal  cataract:  in  real- 
ity an  opacity  in  both  the  lens  and  its 
anterior  capsule.  The  disturbance  in 
vision  depends  upon  the  extent  of  the 
capacity.  Treatment,  as  a  rule,  is  un- 
availing, except  the  possibility  of  an 
optical  iridectomy  should  the  opacity  be 
large  and  the  pupil  small. 

When  the  opacity  is  situated  at  the 
opposite  pole  of  the  lens,  the  condition 
is  designated  as  posterior  polar  cataract, 
or  posterior  pyramidal  cataract.  In  most 
instances  the  latter  form,  which  is  not 
a  true  cataract,  is  congenital  in  type,  and 
is  due  to  some  interference  with  the  in- 
complete disappearance  of  the  hyaloid 
artery.  It  is  recognized  as  a  small  dot 
or  point  on  the  posterior  capsule  at  the 
posterior  pole   of  the   lens,   projecting 


backward  into  the  vitreous  humor.  True 
posterior  polar  cataract  is,  at  times, 
found  as  the  initial  point  of  election  of 
the  senile  form,  and  is  not  infrequently 
seen  associated  with  uveal  disorder  as- 
sociated with  lymph-stream  disturbance 
and  liquefaction  of  the  vitreous  body. 
Generally  it  appears  in  the  stellar  form 
of  opacity.  In  this  variety  interference 
with  vision  depends  not  only  upon  the 
size  of  the  opacity,  but  also  upon  con- 
comitant and  relevant  changes.  Treat- 
ment, to  be  of  any  avail,  must  be  di- 
rected, if  possible,  toward  any  existing 
cause. 

A  third  form,  although  separated  into 
quite  a  series  of  groupings,  consists  of 
localizations  in  various  parts  of  the  lens. 
Opaque  stripes  extending  from  pole  to 
pole,  and  often  combined  with  the  cen- 
tral and  the  zonular  forms,  are  known 
under  the  name  of  "spindle-shaped"  or 
"fusiform"  cataract.  Minute  dots,  usu- 
ally mostly  situated  in  the  central  por- 
tion of  the  lens,  and  frequently  grouped 
in  the  anterior  cortex,  are  known  as 
punctate    cataract.      Small    spheroidal 


Posterior  cortical  cataract.     (Sic/iei.) 

opacities  in  the  nucleus,  of  congenital 
type,  have,  by  some,  been  described  as 
central  cataract.  As  a  rule,  tliey  are  all 
mere  concomitants  of  gross  intra-ocular 
pathological  change. 

Zonular  opacities  situated  between  the 
nucleus  and  the  cortex  of  the  lens,  both 
of  these  portions  being  transparent,  are 


CATARACT.    SYMPTOMS. 


not  uncommon.  At  times  they  may 
progress  as  a  series  of  minute  opaque 
processes,  or  '"riders,"  as  they  are  termed, 
rendering  the  entire,  lens  opaque.  This 
variety  of  cataract,  also  known  as  peri- 
nuclear or  lamellar,  is  either  congenital 


Congenital  cataract  with  riders.     (Sichel.) 

or  forms  during  infancy  in  rachitic  sub- 
jects or  those  who  have  been  afEected 
with  convulsions.  Usually  it  is  binocu- 
lar, but  it  may  occur  in  but  one  eye,  and 
almost  without  exception  is  but  very 
slowly  progressive,  though  cases  in  which 
the  opacity  has  become  total  have  been 
reported.  Upon  account  of  the  situa- 
tion of  the  main  opacity  or  opacities, 
vision  is  usually  markedly  disturbed, 
necessitating  either  artificial  mydriasis, 
iridectomy,  or  lens-removal. 

If  the  appearance  of  the  lens  shows 
that  the  opacity  is  probably  stationary, 
and  if  the  zone  of  the  opacity  be  not 
so  broad  that,  after  the  pupil  has  been 
dilated  with  a  mydriatic,  vision  is  bet- 
tered, it  is  advisable  to  expose  a  portion 
of  the  transparent  periphery  of  the  lens 
by  an  iridectomy,  thus  obtaining  an 
eccentric  clearer  pupil  through  which 
the  subject  can  look.  If,  on  the  other 
hand  the  peripheral  zone  of  transparent 
lens-matter  be  narrow,  and  if  there  be 
evidences  of  increase  in  the  cataract,  it 
is  preferable  to  remove  the  lens,  either 
by  extraction,  when  the  nucleus  is  well 


hardened,  or  by  discission,  when  the 
lens-matter  appears  soft. 

Traumatic  Cataract. — As  a  rule, 
this  form  of  lenticular  opacity  is  the  re- 
sult of  a  rupture  or  disturbance  of  the 
capsule  of  the  lens  from  an  injury  which 
permits  the  aqueous  or  vitreous  humor 
to  come  into  contact  with  the  lens-fibres. 
The  laceration  in  the  capsule  may  be 
caused  by  either  direct  injury  by  means 
of  the  penetration  of  a  foreign  body  or 
indirectly  by  contusion. 

Shortly  after  the  capsular  laceration 
the  lens-fibres  near  the  rent  begin  to 
cloud  and  swell.  Later,  if  it  be  the  ante- 
rior capsule  that  is  injured,  they  ooze  out 
into  the  anterior  chamber,  appearing  as 
gray,  fluffy-looking  masses.  The  aque- 
ous humor,  however,  soon  dissolves  the 
lens-masses  that  have  passed  into  the 
anterior  chamber,  and,  gaining  freer 
access  to  the  interior  of  the  lens  by  the 
removal  of  the  primary  plugs  of  lens- 
matter,  causes  more  or  less  of  the  lens- 
substance  to  become  opaque,  swelled, 
and  absorbed.     In  this  way,  after  the 


''"r,  „,,;„:  r- 


Congenital,  nuclear,  and  perinuclear  cataract. 
(Sichel.) 

lapse  of  some  time,  the  major  portion  of 
the  lens-substance  may  be  dissolved  and 
the  pupil  again  become  almost  black. 
In  most  cases,  however,  the  capsular 
wound  cicatrizes  and  becomes  closed, 
stopping  the  process  of  absorption  before 
the  removal  of  the  lens-material  by  the 


CATAHACT.    SYilPTOMS. 


spontaneous-liquefying  method  is  fully 
attained. 

Many  cases  of  traumatic  cataract  pur- 
sue their  course  with  but  few  signs  of 
inflammation,  but  a  successful  termina- 
tion is  often  prevented  by  the  develop- 
ment of  iritis  caused  either  by  direct  in- 
jury or  by  pressure  of  loose  or  swelled 
lens-matter.  Septic  matter  may  be  also 
introduced  into  the  eye  either  at  the 
time  of  the  traumatism  or  later,  giving 
rise  to  iridocyclitis,  panophthalmitis, 
and  even  periophthalmitis.  If  not  pre- 
vented it  not  infrequently  happens  that 
secondary  glaucoma  supervenes.  This 
condition  is  generally  due  to  either  a 
blocking  of  the  angle  of  the  anterior 
chamber  by  pressure  or  the  presence  of 
a  mass  of  lens-matter  obstructing  the 
passage  of  the  aqueous  humor  through 
the  spaces  of  Fontana. 

The  increasing  forms  of  cataract  are 
roughly  divided  into  four  stages.  As  a 
rule,  they  begin  in  isolated  areas,  but 
increase  and  multiply  until  all  of  the 
lens-substance  is  aifected.  The  most 
frequent  form  is  that  known  as  senile 
cataract. 

In  the  first,  or  incipient,  stage  the 
opacities  usually  begin  in  the  periphery 
of  the  lens.  They  appear  either  in  the 
form  of  spots  or  of  stria,  which  radiate 
from  the  lenticular  equator  toward  the 
centre  of  the  lens.  This  condition  is 
known  as  cortical  cataract.  In  other 
cases  the  nucleus  of  the  lens  may  become 
quite  hazy  and  opaque,  while  the  periph- 
ery may  remain  comparatively  clear. 
This  variety  is  ordinarily  designated  as 
nuclear  cataract.  In  most  instances, 
however,  the  two  forms,  in  which  both 
the  cortical  and  the  nuclear  portions  of 
the  lens  are  affected,  are  associated. 

Clinically,  in  the  stage  of  development 
of  the  cataract  the  anterior  chamber  will 
be  found  but  slightly  shallowed  or  of 


normal  depth,  and  the  opacities  will,  by 
oblique  illumination,  appear  as  white  or 
gray  streaks  and  sectors  with  dots. 

In  the  second  stage,  or  that  of  ripen- 
ing, the  lens  is  swelled,  this  being  due 
to  the  fact  that  it  contains  an  increased 
quantity  of  fluid.  The  opacities  are 
more  pronounced,  while  numerous  clear 
spaces  are  scattered  throughout  the  lens- 
substance.  As  a  rule,  the  anterior  sur- 
face of  the  lens  has  an  iridescent,  bluish- 
white  appearance.  The  anterior  cham- 
ber is  shallow.  Clear  spaces  situated  in 
the  lens  between  the  iris  and  the  opaque 
portions  of  the  lens-substance  can  be 
recognized  by  oblique  illumination, 
allowing  a  shadow  of  the  iris  to  be  cast 


Well-advanced  cortical  cataract.     {Sichel.) 

upon  the  lens  at  the  side  from  which  the 
light  is  thrown. 

In  the  third,  or  mature,  stage  the 
lens  has  returned  to  its  normal  size,  this 
being,  in  great  measure,  due  to  the  loss 
of  the  lenticular  fluids  by  resorption. 
The  clear  spaces  in  the  lens-substance 
are  replaced  by  opacities,  and  the  ante- 
rior chamber  has  regained  its  normal 
depth.  The  iris  fails  to  cast  a  shadow. 
The  lens  presents  a  dull-gray  or  waxy 
appearance,  and  its  anterior  face  is  seen 
to  be  situated  on  a  level  with  the  pupil- 
lary margin  of  the  iris.  Should  the 
pupil  be  artificially  dilated,  it  will  be 
found  that  the  red  reflex  from  the 
fundus,  which   can  be  dimly   obtained 


CATAKACT.    SYMPTOMS. 


while  the  cataract  is  in  its  immature 
stage,  is  lost. 

In  the  fourth,  or  hypermatnre,  stage, 
as  a  rule,  one  of  two  changes  occurs: 
either  the  cortical  substance  disinte- 
grates and  becomes  fluid,  while  the 
nucleus  remains  hard, — so-called  "Mor- 
ganian  cataract," — or  the  broken-down 
cortical  substance  becomes  more  greatly 
inspissated  and  dries  into  a  hard  and 
somewhat  flattened  mass. 

In  hypermature  cataract  the  anterior 
chamber  is  of  normal  depth,  the  iris  fails 


Section  through  Morganian  cataract. 
{Becker.) 

to  cast  any  shadow,  and  the  surface  of 
the  lens  appears  either  homogeneous  or 
exhibits  irregular  dots  in  the  situation 
of  the  ordinary  physiological  sectors.  If, 
however,  the  overripening  process  be 
more  advanced,  fatty  and  calcareous  de- 
generation occurs  in  the  lens  and  its  cap- 
sule, the  anterior  chamber  becomes 
deeper  than  normal,  and  tremulousness 
of  the  iris  can  be  seen. 

In    Morganian    cataract    the    nucleus 


may  sink  to  the  bottom  of  the  liquid 
contents  contained  within  the  lens-cap- 
sule, the  walls  of  the  capsule  may  come 
in  contact  with  one  another,  and  the 
volume  of  the  lens-mass  become  increas- 
ingly smaller  until  nothing  but  a  thin, 
transparent  membrane  remains:  so- 
called  "membranous  cataract." 

Practically,  according  as  the  dimen- 
sions of  the  nucleus  of  the  lens  vary,  a 
cataract  is  spoken  of  as  hard  or  soft. 
When  there  is  no  hard  nucleus  the  cat- 
aract is  said  to  be  soft;  so  that,  as  a 
rule,  all  cataracts  occurring  in  persons 
under  35  years  of  age  fall  under  this 
category.  In  older  subjects,  however, 
the  lenticular  nucleus  is  larger  and  more 
or  less  sclerosed;  so  that  opacities  occur- 
ring in  such  persons  are  designated  as 
hard  cataracts,  although  the  cortices  of 
such  lenses  may  be  quite  soft. 

In  some  senile  cataracts  the  general 
sclerosis  becomes  so  pronounced  that  the 
entire  lens  is  involved  in  it.  In  such 
a  condition  the  cataract,  as  a  rule,  ap- 
pears a  dense,  reddish  brown  and  mark- 
edly translucent.  This  variety  is  usu- 
ally termed  'Tjlack  cataract." 

Secondary  Cataract. — This  condi- 
tion refers  to  the  changes  that  are,  at 
times,  observed  in  the  capsule  of  the 
lens  following,  for  example,  extraction  of 
cataract.  It  is  frequently  seen  after  the 
attempted  removal  of  an  immature  cat- 
aract in  which  a  portion  of  the  lens- 
substance  remains.  This  occurs  when 
the  capsular  membranes  become  agglu- 
tinated together  and  the  escape  of  any 
remaining  lens-material  is  prevented. 
In  many  instances  it  happens  that  the 
entire  pupillary  area  is  not  covered  by 
the  opacity,  and  fairly-satisfactory  vision 
may  be  obtained. 

When  the  condition  does  not  develop 
until  some  months  after  the  primary  op- 
eration for  extraction,  it  is  generally  de- 


CATARACT.     ETIOLOGY. 


pendent  upon  a  fresh  proliferation  of  the 
epithelial  layer,  with  reduplication  of  the 
capsule. 

Etiology. — Congenital  conditions  op- 
erating upon  the  causation  of  cataract, 
which,  at  times  based  upon  well-founded 
clinical  observation,  have  been  deter- 
mined to  be  hereditary  in  type,  prac- 
tically resolve  themselves  either  into 
developmental  disturbances  in  the  eye  or 
antenatal  inflammatory  reaction  of  the 
organ. 

Tlie  influence  of  heredity  in  the  pro- 
duction of  cataract  traced  through  sbc 
generations.  In  no  instance  was  there 
any  evidence  of  consanguinity.  The 
transmission  was  effected  by  females 
alone.  Fromaget  (Gaz.  Hebd.  des  Sci- 
ences M6d.  de  Bordeau.x,  July  30,  '93). 

Senile  change  does  not  produce  cata- 
ract, but  predisposes  to  it;    the  efficient 
determining  causes  are  both  ocular  and 
general,   while    the   general    causes    are 
not   particular  diseases,  but  the  condi- 
tions  arising  in   the   course'  of   disease. 
Jackson   (Universal  ^led.  .Journal,  Dec, 
'93). 
General  disease,  independent  of  senil- 
ity, particularly  if  of  vascular  or  lym- 
phatic type,  becomes,  at  times,  a  causa- 
tive factor.     Thus,  diabetes  mellitus  is 
responsible  for  about  1  per  cent,  of  cases, 
this  variety  being  bilateral  and  develop- 
ing  rapidly.      Rachitis,   nephritis,    and 
some  affections  of  the  skin  are  credited 
with  the  production  of  the  condition. 

Cataract  atl'ecting  primarily  the  pos- 
terior pole  and  cortex  is  not  uncommon 
in  association  with  retinitis  pigmentosa 
and  other  diseases  of  the  pigmentary 
coat  of  the  eye;  but,  apart  from  these 
conditions,  the  presence  of  this  variety 
of  opacity  of  the  lens  is  strongly  indic- 
ative of  the  presence  of  some  serious 
interference  with  proper  tissue  metab- 
olism, and,  of  all  such  alterations,  by 
far  most  frequently  of  diabetes.  The 
special  form  which  the  variety  takes  is 
that  of  a  rounded  central  posterior 
polar  opacity,  along  with  the  formation 


of  striie  in  the  posterior  layers  of  the 
cortex,  these  strise  being  broad  at  the 
equator  of  the  lens,  with  their  apices 
pointed  to  the  posterior  polar  region. 
These  strise  become  broader  and  broader 
at  the  expense  of  the  intervening  clear 
portions,  and  then  the  opacity  spreads 
to  the  anterior  cortical  layers,  and  last 
the  central  portions  become  non-trans- 
parent.   The  author  thinks  that  there 


Formative  changes  in  a  dcgenenUing  lens. 
{Becker.) 

is  quite  a  sharp  line  of  distinction  into 
two  classes  of  cataract  in  regard  to  this 
matter.  In  one,  the  anterior  cortex  la 
affected  before  the  posterior;  this  is  the 
ordinary  senile  cataract.  In  the  other 
the  posterior  cortex  and  pole  are  af- 
fected first,  as  described  above;  this  is 
the  form  associated  with  choroidal  dis- 
ease and  metabolic  anomalies.  Klein 
(Wiener  klin.Wochen.,4,5,  1901;  Ophthal- 
mic Keview,  April,  1902). 

Certain  tonics,  such  as  ergot  and  naph- 
thalin  introduced  into  the  system,  are 
eminently  causal  in  character. 

Local  diseases  and  traumatism  fre- 
quently produce  all  forms  and  varieties, 


CATARACT.  PATHOLOGY.  PROGNOSIS. 


especially  in  changes  affecting  the 
Ijmph-stream  formation  and  circulation, 
and  where  the  solvent  power  of  the 
lymph-fluids  can  be  made  to  exert  their 
influence  directly  upon  th,e  unprotected 
and  exposed  fibres  themselves. 

Influence  of  astigmatism  in  the  genesis 
of  cataract:  in  33  cases  of  bilateral  cata- 
ract, 20  were  found  in  which  the  more 
astigmatic  eye  first  became  cataractous, 
5  were  seen  in  which  the  less  astigmatic 
eye  was  first  afl^ected,  and  8  in  which 
astigmatism  was  either  absent  or  equal 
in  the  two  eyes.  Astigmatism  should 
not  be  considered  a  cause  of  cataract, 
but  rather  as  simply  a  condition  which 
favors  its  development.  Roure  (Recueil 
d'Ophtal.,  Jan.,  '95). 

Attention  called  to  the  frequency  of 
hard  cataract  in  bottle-finishers,  who 
are  exposed  to  the  brilliant  light  and 
intense  heat  of  a  furnace  during  their 
working  hours.  Both  eyes  are  practi- 
cally always  afl'eeted.  The  disease  be- 
gins early  in  life  and  progresses  slowly. 
It  usually  starts  as  a  posterior  polar 
cortical  cataract.  The  disease  can  be 
prevented  by  wearing  dark-blue  specta- 
cles. Six  cases  are  reported.  Robinson 
(Brit.  Med.  Joui-.,  Jan.  24,  1903). 

Pathology. — By  most  recent  author- 
ity, cataract  is  said  to  be,  as  a  rule, 
caused  by  a  too-rapid  sclerosis  and 
shrinkage  of  the  nucleus.  As  one  of  the 
results,  a  cessation  in  the  growth  of  the 
surrounding  lens-fibres  takes  place. 
These  separate  from  one  another  at  cer- 
tain places,  especially  in  the  area  be- 
tween the  nucleus  and  the  cortex,  and 
particularly  in  the  equatorial  region  of 
the  former,  producing  fissures  or  cavities 
that  gradually  become  filled  with  an 
albuminous  liquid,  which  coagulates  and 
produces  spheroidal  bodies  known  as  the 
spheres  of  Morgagni.  Later,  the  lens- 
fibres  which  constitute  the  walls  of  the 
fissures  become  translucent  and  un- 
equally swelled,  giving  rise  to  large  and 
mostly    nucleated    vesicles    of    varying 


sizes  and  shapes.  After  total  disintegra- 
tion of  these  fibres  and  cells  with  their 
remains  has  fairly  well  taken  place,  the 
epithelium  of  the  lens  becomes  abnor- 
mally thickened,  the  most  peripheral 
lens-fibres  become  vacuolated,  and  the 
capsule  of  the  organ  becomes  abnormally 
separated  by  the  pathological  process  at 
work.  In  contrast  to  this  breaking-down 
of  the  cortex,  the  shninken  and  hard- 
ened nucleus,  as  a  rule,  remains  prac- 
tically unchanged. 

In  tlie  various  forms  of  congenital 
cataract  the  course  of  events  may  prob- 
ably be  traced  in  this  manner:  An  in- 
flammatory process  has  attacked  the 
difl'erent  eyes  in  varying  intensity;  the 
ribbon-like  opacity  which  each  cornea 
bears  as  an  evidence  of  this  is  most 
marked  in  the  eyes  with  most  posterior 
synechiiE  and  capsular  cataract.  Fol- 
lowing the  disturbance  in  nutrition  pro- 
duced by  the  inflammatory  attack,  the 
capsular  epithelium  and  lens  degenerate, 
and,  in  consequence  of  shrinking  proc- 
esses, rupture  of  the  posterior  capsule 
ensues.  The  gap  is  filled  up  by  a  capsu- 
lar cataract,  and  thence  arises  an  ad- 
hesion of  capsule  to  lens-substance.  In 
one  case  witnessed  occlusion  did  not 
take  place  and  the  lens-fibres  grew  out- 
ward. After  the  inflammatory  process 
had  run  its  course  (and  it  lasted  a  vari- 
able time  in  the  different  cases)  lens- 
fibres  were  developed,  the  plentifulncsa 
and  quality  of  which  depended  on  the 
condition  of  the  epithelium.  E.  V.  Hip- 
pel  (Von  Grade's  Archiv  f.  Ophthal., 
liv,  1,  1902). 

Prognosis. — The  diagnosis  of  cataract 
being  once  established,  it  frequently  be- 
comes necessary  to  be  able  to  decide  how 
long  it  will  take  for  the  cataract  to  be- 
come mature,  or  what  is  known  aa 
"ripe."  Tliis  is  very  dilTicult,  as  the 
rate  of  progress  is  extremely  variable. 
Senile  cataracts  may  require  years  to  be- 
come sudiciently  opaque  and  hardened 
for  operative  interference,  while,  on  the 
contrary,  in  a  few  rare  instances,  they 


CATAKACT.     PROGNOSIS. 


have  ripened  over  night.  It  is  gener- 
ally wise,  therefore,  if  the  signs  of  cat- 
aract be  discovered  in  elderly  persons 
not  to  alarm  them  by  telling  them  of  its 
existence,  as  vision  may  not  be  seriously 
disturbed  for  a  long  time.  Particularly 
is  this  so  in  nervous  females  in  frail 
health.  Under  all  circumstances,  how- 
ever, it  is  better  that  the  diagnosis  be 
communicated  to  some  responsible  friend 
or  relative  of  the  patient.  At  times, 
among  men  especially,  those  who  are 
harassing  themselves  with  monetary  and 
business  affairs,  it  is  best  to  acquaint 
them  with  the  nature  of  the  disturbance 
in  order  that  better  hygienic  living  may 
be  obtained. 

As  a  general  rule,  cataracts  in  the 
young,  those  due  to  general  dyscrasia, 
and  the  secondary  forms,  all  develop 
rapidly.  On  the  contrary,  all  forms  of 
opacity  which  commence  in  the  periphery 
as  narrow  radii  are  slower  in  extension 
than  those  in  which  there  are  dot-like 
and  broader  opacities. 

In  reference  to  the  prognosis  of  the 
result  of  operative  interference  for  the 
removal  of  cataract,  numerous  factors 
must  be  taken  into  consideration.  In 
many  cases  it  is  essential  to  determine 
the  probable  condition  of  the  interior  of 
the  eye  by  means  of  the  so-called  candle- 
test.  No  matter  how  dense  a  cataract 
may  be,  a  patient  with  a  healthy  fundus 
should  be  able  to  recognize  the  position 
of  a  candle-liglit  placed  in  all  parts  of 
the  visual  field  while  the  organ  is  con- 
stantly directed  toward  a  second  candle 
situated  at  a  central  fixation-point.  If 
the  moving  light  be  lost  at  any  point  in 
the  field,  a  disturbance  of  one  or  more 
of  the  ocular  tunics  may  be  diagnosed 
with  almost  certain  precision  and  the 
prognosis  rendered  relatively  unfavor- 
able. If  all  light-perception  be  lost,  op- 
erative procedure  would  be  useless.    The 


condition  of  the  appendages  of  the  eye 
must  be  noted,  and  any  disease  of  them 
should  be  carefully  treated. 

The  state  of  health  of  the  patient 
should  be  good  as  possible.  General 
dyscrasia  and  old  age  do  not  contra- 
indicate  operative  interference,  although 
they  render  the  chances  of  a  successful 
termination  somewhat  less. 

Profound  anaemia,  depressed  mental 
conditions,  and  pulmonary  complica- 
tions, on  the  other  hand,  are  all  ex- 
tremely apt  to  militate  greatly  against 
any  operative  success. 

The  surroundings  of  the  patient,  the 
cliaracter  of  the  place  of  operation,  the 
time  of  year,  and  the  hour  of  the  day 
must  all  be  taken  into  consideration. 
The  more  aseptic  the  conditions  under 
which  the  operation  is  to  be  performed, 
the  greater  are  the  chances  of  a  success- 
ful termination;  in  fact,  this  is  the 
greatest  of  all  the  prognostic  factors. 
Operations  performed  in  hospitals  are 
much  more  certain  to  be  successful  than 
those  which  are  performed  in  private 
houses. 

In  regard  to  the  effects  of  the  char- 
acter and  the  condition  of  the  cataract 
itself  upon  the  prognosis,  the  general 
rule  is  that  the  more  nearly  mature  the 
cataract  is,  the  more  certain  are  the 
chances  of  resultant  good  vision.  In 
some  very  old  subjects,  where  the  nu- 
cleus of  the  lens  is  large  and  well  scle- 
rosed, extraction  may  be  made  with 
every  chance  of  eventual  success.  Op- 
erations upon  overripe  cataracts  are  not 
apt  to  be  very  successful.  The  frequency 
of  fluid  vitreous,  the  degenerate  condi- 
tion of  the  zonule,  and  the  density  of 
the  capsule,  all  are  serious  complicating 
conditions. 

Reports  of  400  extractions  of  senile 
cataract  by  Prof,  von  Rothmund,  of 
which  25  were  complicated:    The  visual 


10 


CATARACT.    TREATMENT. 


acuity  ■was  satisfactory  (at  least  Vw)  ^ 
63.5  per  cent.;  1.7  per  cent,  ^vere  total 
faOures.  Prognosis:  while  positive  re- 
sponse to  the  usual  tests  is  in  general 
favorable,  it  does  not  absolutely  exclude 
disappointments.  Thus,  in  1  ease  with 
normal  function  to  ante-operative  tests, 
an  old  detachment  of  the  retina  was 
found  after  extraction.  On  the  other 
hand,  5  cases  with  complete  lack  of 
power  to  recognize  colors  resulted  in 
good  vision  and  presented  no  complica- 
tions whatever.  Of  39  eases  of  hyper- 
mature  cataract  the  vision  was  satisfac- 
tory in  but  18;  in  10  eases  of  adherent 
cataract  the  result  was  satisfactory  in 
5.  Ebner  (Miinch.  med.  Woch.,  vol.  xliv, 
Jahrg.  No.  16,  '97). 

As  long  as  a  person  has  the  capacity 
to  read  with  the  fellow-eye,  it  should  be 
let  alone.    The  moment  he  is  not  able  to 
read  with  the  other  eye,  an  extraction 
should   be   performed,   with    the   under- 
standing that  almost  certainly  a  subse- 
quent needling  operation  of  the  opaque 
capsule    might    be    safely    undertaken. 
Dudley   S.   Reynolds    (Ophthalmic   Rec, 
June,  '98). 
Treatment. — The  removal  of  cataract 
can  be  secured  only  by  operation.     Re- 
ported instances  of  its  cure  by  absorp- 
tion, by  means  of  drngs,  or  by  massage 
are    misleading,    and    usually    emanate 
from  persons  or  institutions  devoted  to 
the  purpose  of  mere  monetary  gain.    It 
it  probable  that  the  temporai7  visual 
improvement  which  is,  at  times,  obtained 
by  such  patients  is  due  to  the  instillation 
of  a  mydriatic,  for,  if  the  opacity  be  cen- 
tral, dilatation  of  the  pupil  may  be  ren- 
dered sufTiciently  large  to  remove  the  iris 
from  before  the  clear  periphery  of  the 
lens,  thus  permitting  vision  through  the 
unobstructed  portion  of  the  lens.     Un- 
fortunately, however,  the  improvement, 
which,  at  best,  is  but  temporary,  lasts 
only  during  the  time  of  the  effect  of  the 
drug. 

Cataract  apparently  chocked  for  eight- 
een monthB  and  for  two  years  by  twice 
a  day   instilling  a   couple   of   drops,   or 


applying,  ^rith  an  eyecup  for  from  one 
to  two  minutes  to  the  open  eyes,  2.5- 
per-cent.  solution  of  ether  iodide,  which 
is  readily  absorbed.  Badal  (La  Semaine 
Medicale,  Nov.  31,  1901). 

Three  cases  of  cataract  treated  by 
iodide  of  potassium  and  sodium  wash. 
These  are  applied  in  a  cup  for  a  few 
minutes,  with  the  eyelids  wide  open, 
twice  a  day.  By  this  treatment  a  cata- 
ract fails  to  progress  further  and  re- 
mains stationary.  Badal  (Jour,  de  M6d. 
de  Bordeaux,  July  21,  1901). 

Potassium  iodide  has  a  marked  effect 
upon  opacities  of  the  crystalline  lens,  in 
that  it  stays  their  progress.  It  also 
promotes  retrogression  of  traumatic  len- 
ticular cataract.  Its  influence  is  very 
slight  in  traumatic  opacities  of  the  cap- 
sule. L.  Verderau  (Revista  de  Ciencias 
Medicas  de  Barcelona,  Jan.,  1903). 

The  development  of  cataract  may  be 
retarded  by  careful  and  repeated  cor- 
rection of  any  existing  anomaly  of  re- 
fraction and  by  constant  care  of  the 
patient's  general  health. 

Operations. — There  are  two  opera- 
tive methods  of  treating  cataract:  one 
by  absorption  and  the  other  by  extrac- 
tion. The  first  is  applicable  to  soft  cat- 
aracts only,  and  is  consequently  limited 
to  those  found  in  young  subjects.  It  has 
for  its  object  the  bringing  of  the  aque- 
ous humor  into  contact  with  the  lens- 
fibres  by  means  of  an  artificial  opening 
made  in  the  anterior  capsule  of  the  lens. 
This  is  accomplished  by  entering  a 
needle,  especially  prepared  for  the  pur- 
pose, through  the  lower  and  outer  or 
upper  and  inner  quadrant  of  the  cornea, 
and  incising  those  portions  of  the  ante- 
rior capsule  of  the  lens  which  arc  situ- 
ated opposite  the  pupillary  area. 

The  pupil  should  have  been  primarily 
dilated  as  much  as  possible  with  some 
eiTicient  mydriatic.  Care  should  always 
be  taken,  particularly  in  very  young  sub- 
jects, that  the  capsular  incisions  are  not 
made  too  extensively  and  that  they  do 


CATAEACT.    TREATMENT. 


11 


not  penetrate  too  deeply  into  the  lens- 
structure,  in  order  that  the  lens-mass  may 
not  be  disturbed  too  greatly. 

General  anjesthesia  is  not  necessary. 
The  instillation  of  a  few  drops  of  a  2- 
per-cent.  solution  of  hydrochlorate  of 
cocaine  is  sufficient  to  render  the  opera- 
tion painless.  The  patient  should  be 
placed  in  a  recumbent  position  and  the 
eyelids  should  be  separated  either  by  a 
speculum  or  by  an  elevator  and  the  fin- 
gers of  an  assistant.  After  the  proced- 
ure a  few  drops  of  sulphate  of  atropine 
should  be  instilled  into  the  conjunctival 
cul-de-sac  and  ice-compresses  applied 
until  the  eye  becomes  free  from  any 
signs  of  operative  irritation. 

If  no  complications  arise  and  there  be 
sufficient  reason,  the  operation  can  be 
repeated  as  soon  as  the  absorption  of  the 
loosened  cataractous  masses  seem  to  have 
been  sufficiently  accomplished  and  the 
mass  itself  has  become  stationary.  The 
incisions  in  the  second  and  any  subse- 
quent operations  may  be  made  more 
freely,  as  the  danger  of  swelling  of  the 
lens-fibres  is  lessened,  this  being  due  to 
the  diminished  volume  of  the  lens-ma- 
terial. In  uncomplicated  cases  the  ab- 
sorption of  the  cataractous  masses  is 
generally  accomplished  in  eight  or  ten 
week's  time. 

It  is  concluded  that:  1.  Certain  len- 
ticular opacities,  most  often  situated  in 
the  naso-inferior  quadrant  of  the  lens, 
occasionally  are  practically  stationary 
and  may  be  designated  "non-progress- 
ive." They  do  not  handicap  the  patient's 
ocular  abilities,  and  may  with  propriety 
be  separated  from  the  class  to  which  the 
name  incipient  eatjiraet  is  ordinarily 
given.  2.  Certain  lenticular  opacities 
undoubtedly  depend  on  what  may  be 
designated  "disturbances  of  the  choroid," 
as  apart  from  active  and  actual  choroi- 
ditis; and  their  progress  is  sometimes 
apparently  checked  by  measures — optical, 
local,  and  general  medicinal — which  re- 
store   the    choroid    coat    to    normality. 


Such  measures  do  not,  however,  remove 
from  the  lens  the  opacities  which  have 
already  formed  when  the  patient  comes 
under  treatment.  3.  Certain  lenticular 
opacities  which  appear  in  association 
with  diabetes  mellitus,  nephritis,  lith- 
femia,  and  arteriosclerosis,  particularly 
the  last  two  diseases,  are  sometimes  ap- 
parently retarded,  like  those  in  No.  2, 
by  measures  which  are  suited  to  the  pa- 
tient's general  condition  in  connection 
with  local  and  optical  therapeutics,  but 
these  measures  never  dissipate  the  lens 
lesions  already  present.  4.  The  extrac- 
tion of  unripe  cataracts  is  preferable  to 
any  of  the  ordinary  operations  for  ripen- 
ing cataract.  5.  Tliere  is  no  evidence 
that  electricity  has  the  slightest  influ- 
ence in  checking  the  rate  of  progress  of 
incipient  cataracts,  or  in  dissipating  the 
opacities  which  have  formed.  6.  There 
is  very  insufficient  evidence,  if  any,  that 
massage  of  the  eyeball  favorably  modi- 
fies the  rate  of  development  of  cataract. 
7.  There  are  no  "specific  remedies"  for 
the  treatment  of  cataract,  and  there  is 
no  reliable  evidence  that  drugs  exist 
which  cause  the  absorption  of  partially 
or  fully  formed  cataracts.  8.  All  lenticu- 
lar opacities,  unless  the  "non-progressive" 
group,  should  indicate  a  thorough  in- 
vestigation of  the  patient  from  the  gen- 
eral as  well  as  the  ocular  stand-point, 
and  the  employment  of  remedies  accord- 
ing to  the  findings.  G.  E.  de  Schwcinitz 
(Jour.  Amer.  Med.  Assoc,  Dec.  8,  1900). 

The  principal  complications  of  the  pro- 
cedure are  iritis  and  secondary  glaucoma. 
The  first  is  supposed  to  be  caused  either 
by  pressure  or  "chemical  irritation"  ex- 
erted by  the  lens-matter  on  the  iris.  As 
a  rule,  it  may  be  prevented  by  keeping 
the  pupil  well  dilated  with  some  power- 
ful mydriatic  or  combination  of  mydri- 
atics. If  the  second  form  of  complica- 
tion appears,  the  lens-matter  should  be 
immediately  removed  by  extraction 
through  a  linear  incision. 

In  traumatic  cataract  the  patient 
should  be  placed  in  bed  as  early  as  pos- 
sible. Ice-compresses  should  be  applied 
either   constantly   or   intermittently   to 


CATAKACT.    TREATMENT. 


the  eye  in  order  to  reduce  inflammatory 
reaction,  and  atropine  slrould  be  in- 
stilled at  regular  intervals  to  prevent  the 
occurrence  of  iridic  inflammation.  Or- 
dinarily under  such  plan  of  treatment, 
the  lens-substance  will  gradually  absorb 
without  any  complicating  disturbances. 
The  danger  of  secondary  glaucoma  with 
its  accompanying  symptoms  should  never 
be  lost  sight  of,  and  intra-ocular  tension 
should  be  repeatedly  tested.  If  such 
sjTnptoms  should  intervene,  as  much  of 
the  lens-matter  as  proper  at  the  time 
should  be  removed  without  delay.  This 
may  be  readily  accomplished  by  a  sim- 
ple incision  through  the  cornea  into 
the  anterior  chamber  and  the  soft- 
ened lens-masses  carefully  and  gently 
coased  out  along  the  groove  of  a  Daviel 
Bpoon. 

In  operating  upon  shrunken  or  mem- 
branous cataracts,  it  is  not  so  essential 
to  provoke  absorption  of  the  remaining 
cataractous  material  as  it  is  to  obtain 
a  clear  space  in  the  toughened  and 
opaque  capsule  through  which  vision  can 
be  gotten.  The  operation  is  ordinarily 
performed  by  means  of  two  needles 
which  are  passed  rather  obliquely 
through  the  cornea,  one  near  to  the  nasal 
and  the  other  close  to  the  temporal 
border  of  the  membrane.  This  done, 
both  are  pushed  backward  into  the 
chosen  portion  of  the  opacity,  and  the 
points  of  the  instruments  separated  from 
one  another  in  such  a  manner  that  no 
traction  is  exerted  upon  the  iris  and 
ciliary  body,  thus  producing  a  clear  hole 
in  the  membranous  mass. 

Complete  atropinization  of  the  eye  be- 
fore extraction  of  cataract  is  extremely 
favorable  to  the  successful  issue  of  the 
operation.  Confirmed  by  a  trial  of  the 
method  in  170  cases.  Out  of  these,  pro- 
lapsus of  the  iris  occurred  only  in  7 
cases, — i.  e.,  4  per  cent.,  wliile  before  the 
use  of  atropine  the  percentage  of  pro- 


lapsus  was    15.      Muttermilch    (Gazeta 
Lekarska,  No.  9,  '96). 

Simple  linear  extraction  is  applicable 
to  the  removal  of  both  the  soft  and  the 
membranous  varieties  of  opacity.  It  is 
preferred  by  many  operators  to  discis- 
sion, and  may  be  employed  in  any  case 
where  the  lens-substance  is  sufficiently 
soft  to  flow  through  a  small  corneal 
wound. 

The  operation  is  performed  as  fol- 
lows: After  a  speculum  has  been  in- 
serted, or  the  eyelids  separated  by  an 
assistant,  the  globe  is  grasped  by  a  fi.xa- 
tion-forceps,  and  the  point  of  a  kera- 
tome  or  the  tip  of  a  von  Graefe  knife 
is  entered  into  the  anterior  chamber 
through  the  cornea,  usually  about  three 
or  four  millimetres  from  the  limbus.  If 
the  former  instrument  is  used,  it  is 
passed  directly  through  the  corneal 
membrane,  but,  as  soon  as  its  tip  enters 
the  anterior  chamber,  the  cutting-blade 
is  laid  upon  a  plane  that  is  parallel  to 
that  of  the  iris.  It  is  then  pushed  forward 
until  the  corneal  wound  has  obtained  a 
length  of  several  millimetres.  It  is  then 
slowly  withdrawn,  in  order  to  prevent 
the  aqueous  humor  from  coming  away 
too  quickly,  with  the  possibility  of  a 
prolapse  of  the  iris.  If  a  von  Graefe 
knife  is  used,  the  movements  given  to 
the  instrument  must  be  very  carefully 
performed,  in  order  to  avoid  wounding 
the  iris-tissue.  A  cystotome  is  passed 
into  the  anterior  chamber  through  the 
same  corneal  wound,  care  also  being 
taken  to  avoid  wounding  the  iris.  Free 
incision  in  the  anterior  capsule  of  the 
lens  is  then  made  with  it.  After  the 
incisions  have  been  accomplished,  the 
cyslotome  is  withdrawn,  and  the  loosened 
lens-matter  is  evacuated,  as  previously 
explained, by  means  of  a  Daviel  spoon.  If 
necessary,  the  operation  may  be  done 
with  the  addition  of  an  iridectomy.    In 


CATAKACT.    TREATMENT. 


13 


this  event,  the  corneal  incision  is  made 
nearer  the  limbus  and  should  be  slightly 
longer.  After  the  withdrawal  of  the 
knife,  the  tips  of  an  iris-forceps  are  to 
be  introduced  into  the  anterior  chamber 
and  a  fold  of  iris  directly  over  the 
sphincter  of  the  pupil  grasped  and  gently 
drawn  through  the  wound  and  cleanly 
snipped  off  with  a  pair  of  fine  scis- 
sors. Cystotomy  and  extraction  of  the 
lens-massings  then  follow,  a  just  de- 
tailed. 

As  it  frequently  happens  that  lens- 
matter  is  left  behind,  a  number  of  opera- 
tors practice  its  removal  by  suction- 
syringes  of  special  construction.  The 
procedure,  however,  has  never  obtained 
general  favor. 

The  operation  for  the  removal  of  a 
hard  cataract  consists  essentially  of  three 
steps:  the  corneal  incision  of  sufficient 
size  to  permit  of  the  passage  of  the  lens; 
an  incision,  or  a  series  of  them,  into  the 
anterior  capsule  of  the  lens  (cystotomy) 
in  order  to  allow  the  egress  of  the  lens- 
matter  through  it;  and  the  delivery  of 
the  lens-substance  from  the  eyeball  it- 
self. Before  the  actual  operation  is 
made,  certain  preliminary  details  should 
be  carefully  attended  to.  A  general 
warm  bath  should  be  given  to  the  pa- 
tient the  night  before  the  operation. 
Care  should  be  exercised  to  make  his 
head  clean  with  Castile  soap  and  water. 
The  bowels  should  be  relieved  by  a  gen- 
tle laxative,  in  order  that  they  may  not 
be  disturbed  for  the  first  few  days  after 
the  operative  procedure. 

The  instruments,  with  the  exception 
of  the  knives,  which  should  be  immersed 
in  alcohol  for  at  least  twenty  minutes 
prior  to  their  use,  should  be  boiled. 
After  the  cleansing  has  been  completed, 
they  should  be  kept  in  a  tray  of  alcohol 
during  the  entire  operation,  being  dipped 
for  a  few  moments  in  a  tray  of  sterile 


water  just  as  they  are  being  picked  up 
for  use. 

The  patient  having  been  carefully 
prepared  and  the  field  of  operation 
having  been  excluded  from  external  con- 
tamination for  a  couple  of  hours  previ- 
ously by  a  few  turns  of  a  roller  bandage, 
his  eyelids,  eyebrows,  eyelashes,  and 
adjacent  parts  should  be  thoroughly 
washed  with  a  saturated  solution  of  boric 
acid.  The  lids  should  be  gently  everted 
and  the  upper  and  lower  cul-de-sacs 
flushed  with  the  same  character  of  solu- 
tion. Several  drops  of  a  2-per-cent. 
solution  of  hydrochlorate  of  cocaine  are 
then  introduced  into  the  eyes  at  five- 
minute  intervals,  for  about  fifteen  min- 
utes before  the  operation,  care  being 
taken  that  the  eyelids  are  kept  closed 
and  that  a  clean  towel  is  thrown  over 
the  field  of  operation.  If  possible,  the 
patient  should  lie  flat  on  his  back  in  the 
bed  that  he  is  to  occupy.  If  circum- 
stances do  not  permit  this  he  should  be 
placed  upon  some  form  of  operating- 
chair  or  table.  The  source  of  light 
should  be  situated  so  that  there  shall  be 
a  field  of  uniform  illumination  upon  the 
exact  points  to  be  operated  upon.  If 
the  surgeon  be  ambidextrous,  he  may 
place  himself  in  front  of  the  patient  or 
behind  him  in  accordance  with  comfort 
and  existing  circumstances.  A  trained 
assistant  should  be  present  and  assume 
such  a  position  that  he  may  be  able  to 
hand  the  instruments  to  the  surgeon  or 
receive  them  from  him  with  such  skill 
and  rapidity  that  the  operator  may  be 
able  to  keep  his  vision  fixed  upon  the 
field  of  operation  during  the  successive 
stages.  Prior  to  any  procedure  it  is  well 
for  the  surgeon  to  speak  kindly  and 
quietly  to  the  patient  for  a  few  moments 
to  gain  his  confidence  and  at  the  same 
time  inform  him  of  certain  movements  of 
the  eyes  that  may  be  necessary  during 


14 


CATAKACT.    TREATMENT. 


the  operation.  He  should  be  cautioned 
against  holding  his  breath  and  strain- 
ing and  told  to  resist  all  desire  to  close 
his  eyes  forcibly.  By  these  few  injunc- 
tions quietly  and  authoritatively  given, 
the  most  intractable  patients  may  be 
rendered  obedient,  the  soothing  words 
thus  given  often  bearing  fruit  to  the 
surgeon  a  hundredfold. 

All  these  minor,  but  most  essential, 
preliminaries  being  satisfied,  the  eyelids 
are  to  be  separated  by  an  elevator  held  in 
the  hands  of  a  skilled  assistant,  who  is 
capable,  if  necessary,  to  momentarily  re- 
move the  instrument  without  any  dam- 
age to  the  organ.  The  patient  is  asked 
to  look  down.  The  globe  is  firmly  held 
in  any  desired  position  by  gently  taking 
a  fold  of  bulbar  conjunctiva  about  two 
or  three  millimetres'  distance  from  the 
corneal  limbus  within  the  grasp  of  a 
fixation-forceps  held  with  one  hand, 
while  with  the  other  the  corneal  section 
is  to  be  made.  The  knife  most  generally 
employed  is  one  introduced  by  von 
Graefe,  which  consists  of  a  long,  straight, 
narrow  blade  converging  at  its  far  ex- 
tremity into  a  sharp  point.  Unless 
contra-indicated,  the  primary  puncture 
should  he  made  just  within  the  margin 
of  the  clear  cornea  at  the  outer  ex- 
tremity of  a  horizontal  line,  which,  as 
a  rule,  would  pass  three  millimetres  be- 
low the  summit  of  the  membrane.  The 
cutting-edge  of  the  knife  should  be 
situated  upward  and  its  point  directed 
toward  the  centre  of  the  cornea.  After 
the  tip  of  the  knife  has  been  made  to 
enter  the  anterior  chamber,  it  should  be 
carried  directly  across  and  re-entered 
into  the  corneal  tissue  at  the  point  de- 
sired. The  section  should  then  be  com- 
pleted by  an  upward  movement  so  regu- 
lated that  the  corneal  section  is  kept 
true  and  smooth  throughout  its  entire 
extent.     At  this  stage  the  elevator,  in 


uncomplicated  cases,  is  removed  and  not 
used  again.  The  first  stage  of  the  opera- 
tion being  completed,  the  surgeon  next 
addresses  himself  to  the  performance  of 
the  second  stage,  or  that  of  capsulotomy, 
or  so-called  cystotomy.  Directing  the 
patient  to  look  down  and  without  any 
fixation-instrument  in  position,  if  pos- 
sible, he  introduces  a  cystotome,  with  the 
heel  of  the  cutting-point  first,  between 
the  lips  of  the  corneal  wound,  and  inserts 
the  point  of  the  instrument  into  the 
anterior  capsule,  without  dislocating  the 
lens,  in  such  a  manner  as  to  be  able  to 
make  a  series  of  as  free  incisions  as 
he  may  believe  desirable  and  in  such  po- 
sitions as  he  may  deem  the  best.  These 
having  been  obtained,  the  cystotome 
is  withdrawn  in  such  a  way  that  the  iris 
is  not  wounded  during  the  procedure. 
The  avenue  of  escape  for  the  lens  having 
been  made,  it  remains  to  practically  com- 
plete the  operation  by  the  performance 
of  the  third  stage,  or  that  of  the  deliv- 
ery of  the  lens.  The  surgeon  should, 
with  the  ball  of  the  finger-tip  of  one 
hand  upon  the  sclera  just  below  the 
lower  edge  of  the  cornea,  and  a  spatula 
held  in  the  other  hand  and  placed  upon 
the  sclera  just  above  the  corneal  sec- 
tion, make  a  series  of  delicate,  yet  steady, 
upward  and  forward  pressures  and  coun- 
ter-pressures until  just  one-half  of  the 
lens  has  engaged  in  the  corneal  wound, 
when,  by  a  dextrous  and  slightly  tilting 
and  upward  motion  from  side  to  side, 
the  lens  will  emerge  without  any  com- 
plication whatever,  and  the  corneal  flap 
will  fall  smoothly  into  place.  Should 
the  pupil  not  be  round  and  should  any 
lens  debris  be  seen,  the  eyelids  are  to  be 
closed  and  a  slight  gentle  rotary  motion 
be  made  upon  the  globe  through  the 
upper  lid  by  the  fingers.  If  there  be 
any  cortex  remnants,  the  stump  of  the 
flay)  is  to  be  slightly  depressed  and  the 


CATAJaACT.    TREATMENT. 


15 


masses  gently,  though  as  completely  as 
possible,  washed  out  of  the  anterior  and 
posterior  chambers  by  free  irrigation 
from  varying  positions  with  warm  sterile 
water  or  boric-acid  solution  without  the 
introduction  of  any  instrument  whatso- 
ever into  the  chambers. 

After  the  lens  has  been  delivered  and 
anything,  such  as  blood-clots  and  lens 
debris,  which  might  prevent  the  proper 
union  of  the  lips  of  the  corneal  wound 
have  been  removed,  the  conjunctival  cul- 
de-sac  is  to  be  flushed  with  a  warmed 
solution  of  boric  acid  and  the  pupil  and 
corneal  flap  seen  to  be  in  proper  posi- 
tions. The  eyelids  of  both  eyes  are  then 
gently  closed  and  held  together,  if  neces- 
sary, by  one  or  two  narrow  strips  of 
isinglass  plaster, 

A  few  carefully-adjusted  and  smoothly- 
applied  turns  of  gauze  bandage  over 
squares  of  sterilized  gauze  properly  cov- 
ered by  pledgets  of  absorbent  cotton 
should  be  made  without  disturbing  the 
patient.  Strict  injunction  to  remain 
quiet  for  at  least  twenty-four  hours'  time 
should  be  given,  any  necessary  desires 
being  properly  cared  for  by  competent 
attendants. 

Case  in  which  destruction  of  the 
eye  by  htemorrhage  followed  the  extrac- 
tion of  a  cataractous  lens,  which  had 
been  dislocated  downward,  and  which 
was  safely  removed  by  simple  extraction 
without  the  use  of  a  wire  loop  or  of  fixa- 
tion of  the  lona.  A  few  minutes  after 
the  operative  procedure  tlie  patient  com- 
plained of  severe  pain  in  the  temple  and 
back  of  the  head.  An  examination  re- 
vealed the  presence  of  a  copious  hsemor- 
rhage  from  the  corneal  wound,  which 
was  at  once  controlled  by  placing  the 
patient  in  an  upright  position.  There 
was  a  deep  glaucomatous  excavation  in 
the  other  eye,  but  at  no  time  coidd  any 
hfemorrhages  be  observed  in  the  fundus. 
Jackson  (Annals  of  Ophthal.  and  Otol., 
Jan.,  '94). 

The  chief  factor  in   the  causation   of 


ocular  hemorrhage  after  extraction  is 
an  increase  in  the  blood-tension.  Mi- 
croscopical examination  of  an  eye,  which 
was  lost  as  a  result  of  such  an  accident, 
showed  that  the  choroidal  and  retinal 
vessels  had  very  much  thickened  walls 
and  that  there  had  been  a  classical  total 
retrochoroidal  htemorrhage.  The  hism- 
orrhagic  extravasation  seemed  to  have 
originated  at  the  entrance  of  the  pos- 
terior ciliary  vessels  in  the  posterior 
and  external  regions  of  the  choroid,  and 
did  not  occur  untU  three  days  after  the 
extraction  of  the  lens.  Terson  (Archives 
d'Ophtal.,  Feb.,  '94). 

An  instance  of  destructive  hoemorrhage 
during  extraction  of  a  cataract:  The 
patient  was  a  female  82  years  of  age. 
The  liquefied  state  of  the  cortical  sub- 
stance, tlie  presence  of  cholesterin  crys- 
tals in  the  lens,  the  sagging  downward 
of  the  lenticular  mass,  the  tremulous 
irides,  and  finally  the  very  fluid  vitreous, 
all  gave  indications  of  degenerative  proc- 
esses which  had  occurred  in  the  eyes  be- 
fore opacity  of  the  lens  had  taken  place. 
In  this  case  the  prolapse  of  vitreous  fol- 
lowed immediately  on  the  section,  and  a 
hiEmorrhage  appeared  instantly  after  the 
delivery  of  the  lens.  Eisley  (Annals  of 
Ophthal.  and  Otol.,  Jan.,  '94). 

Case  of  double  cataract  extraction  fol- 
lowed by  haemorrhage,  with  subsequent 
restoration  of  vision :  The  subject  was  71 
years  old,  and  in  a  very  poorly  nourished 
condition.  He  was  a  sufferer  from  vari- 
cose veins  over  the  whole  body  and  ex- 
hibited other  evidences  of  vascular  dis- 
ease. Gasparrini  (Annali  di  Ottal.,  Oct., 
Nov.,  '94). 

Intra-ocular  hiemorrhage.  with  subse- 
quent shrinking  of  the  globe,  following 
cataract  extraction  in  a  woman,  78  years 
of  age,  with  degenerative  heart  disease: 
The  patient  died  about  eight  months 
later  from  angina  pectoris.  Lee  (Prac- 
titioner, June,  '95). 

Five  cases  in  which  no  cause  could  be 
assigned  for  the  htemorrhage:  There  was 
no  want  of  smoothness  in  the  course  of 
the  operations  except  in  one  case,  and 
this  was  so  slight  as  to  be  ordinarily  of 
no  significance.  Suggestion  was  made 
that  a  preliminary  iridectomy  is  prob- 
ably a  valimble  measure  in  these  cases, 


16 


CATARACT.    TREATMENT. 


and  when  done  such  have  been  reported 
as  successful.  Wadsworth  (Boston  Med. 
and   Surg.  Jour.,   Sept.   3,   '97). 

Choroidal  hemorrhage  after  cataract 
extraction  is  by  no  means  so  rare  as  has 
been  thought.  Over  50  cases  have  been 
reported,  and  many  remain  unpublished. 
It  is  due  solely  to  the  diathesis  of  the 
patient,  the  principal  cause  being  an 
atheromatous  condition  of  the  vessels, 
or  an  abnormal  tension  of  the  eyeball, 
suddenly  reduced  by  the  incision  in  the 
cornea  and  the  outflow  of  aqueous. 
When  such  a  haemorrhage  occurs  the 
best  treatment  is  to  raise  the  patient's 
head,  to  relieve  the  pain,  and  to  watch 
the  eye  carefully,  at  the  same  time  being 
prepared  to  perform  enucleation  as  early 
as  possible.  J.  A.  Spalding  (Archives  of 
Ophthal.,  vol.  XV,  No.  1,  '97). 

Local  changes  in  the  choroidal  veins 
predispose  to  post-operate  hemorrhage 
within  the  eye.  Bloom  (Graef's  Ar- 
chives, July  19,  '98). 
If  no  pain  be  complained  of,  the  dress- 
ings should  be  allowed  to  remain  for 
twenty-four  hours,  at  the  end  of  which 
time  they  should  be  removed,  the  eye 
inspected,  and  the  conjunctival  cul-de- 
sac  gently  flushed  with  a  solution  of 
boric  acid.  If  all  has  gone  well  it  will  be 
found  that  the  anterior  chamber  has  re- 
established itself  and  that  the  eye  is 
quiet.  If  there  be  any  injection,  if  the 
pupil  is  small,  or  if  any  sign  of  inflam- 
matory reaction  be  present,  a  drop  or 
two  of  sulphate  of  atropine  or,  better, 
hydrochlorate  of  scopolamine  should  be 
instilled.  At  the  end  of  forty-eight 
hours'  time  the  dressing  over  the  sound 
eye  may  be  removed,  but  that  on  the 
operated  eye,  which  can  be  made  lighter, 
should  be  allowed  to  remain  for  another 
day,  when  plain  smoked  glasses  or,  if 
unobtainable,  a  suitable  shade  can  be 
worn. 

To  prevent  tendency  to  prolapse  of 
the  iris  and  to  favor  smooth  healing 
of  the  corneal  incision,  it  is  essential 
that  the  patient  should  rest  absolutely 


quiet  in  bed  for  the  first  forty-eight 
hours.  If  he  be  old  and  feeble,  more 
latitude  can  be  given  to  his  movements, 
which  must  be  accomplished  by  the  aid 
of  careful  attendants.  At  the  end  of 
the  second  day,  a  bed-rest  may  be  em- 
ployed, and  on  the  third  day,  if  the 
healing  has  been  uncomplicated  (which 
under  the  circumstances  will  be  so  almost 
without  exception),  the  patient  may  be 
allowed  to  sit  up.  For  the  first  twenty- 
four  to  forty-eight  hours  the  diet,  which 
is  to  be  regularly  given,  should  be  liquid 
and  semisolid.  On  the  third  day  the 
bowels  can  be  opened  by  a  gentle  laxa- 
tive. After  this,  liberal  nourishment 
may  be  ordered. 

Although   reelination    of   the   lens   in 
the  very  aged  at  one  time  was  largely 
employed,  and  is  still  to   some  extent, 
personal    observations    at    Hirschberg's 
clinic  has  shown  that  e.xtraction  is,  after 
all,   the   most   feasible   procedure,   even 
very  late  in  life.     The  author's  observa- 
tions   embrace    1645    cases    of    nuclear 
cataract,   among   which    there    were   36 
patients  over  80  j'ears  of  age.     Only  in 
2   cases   were   the   results   not   entirely 
satisfactory.     Advanced    age    does    not, 
therefore,  offer  an  unfavorable  progno- 
sis   for    cataract    extraction.     In    very 
restless  patients  general  anajstliesia  may 
be  employed.    Delirium  will  occasionally 
occur,   but   the   most   serious   complica- 
tions  are   those   related   to   the   heart, 
lungs,  and  bladder.     In  one  case   heart 
disease  gave  rise  to  piilmonary  oedema, 
which,  however,  was  controlled  by  mor- 
phine.    Mendel     (Berliner    klin.    Woch., 
Aug.  12,  1901). 
The  operation  which  has  just  been  de- 
scribed is  what  is  known  as  simple  ex- 
traction, or  extraction  without  iridec- 
tomy and  is  the  one  that  is  ordinarily 
in  use  to-day  and  should  be  the  one 
chosen   in   all  suitable  cases  in  which 
there  are  no  contra-indications. 

One  hundred  consecutive  extractions; 
extraction  without  iridectomy  preferred ; 
Knapp's    method    of    making    the    cap- 


CATARACT.    TREATMENT. 


17 


sulotomy  followed.  Discission  resorted 
to  in  88  per  cent,  of  private  eases  and  CO 
per  cent,  of  liospital  cases,  tlie  operation 
being  performed  about  three  weeks  after 
extraction.  No  cause  to  regret  the  ex- 
traction of  an  immature  cataract.  Weeks 
(N.  Y.  Med.  Jour.,  Aug.  3,  '95). 

Study  and  comparison  of  1032  cases  of 
combined  extractions  and  1123  cases  of 
simple  extractions:  Conclusion  that  the 
simple  method  extraction  is  far  superior 
to  all  others  in  the  very  great  majority 
of  eases,  and  that,  while  it  is  a  somewhat 
more  dilBcuIt  operation  than  the  com- 
bined method,  any  experienced  surgeon 
will  find  the  results  proportionately 
greater.    King  (Med.  Rec,  Feb.  23,  '95). 

Details  of  1519  cases  in  which  the 
operation  of  extraction  was  performed 
during  the  five  years,— 1889  to  1893  in- 
elusive,- — in  the  practice  of  eleven  dif- 
ferent surgeons:  Extractions  with  iri- 
dectomy, 1091,  as  against  276  in  which 
simple  extraction  was  performed;  while 
161  had  an  iridectomy  done  some  weeks 
at  least  before  the  cataract  was  removed. 

The  percentage  of  successful  cases  only 
amounted  to  83.78,  and  13.51  had  no 
useful  vision.  Of  all  the  1519  cases  the 
percentage  of  enucleation  after  extrac- 
tion amounted  to  1.90.  Although  nee- 
dling is,  as  a  rule,  such  a  simple  proced- 
ure, yet  many  cases  subsequently  do 
badly.  Glaucoma  occurred  in  2.08  per 
cent,  of  the  cases  after  secondary  opera- 
tions on  the  capsule,  while  it  occurred  in 
only  0.42  per  cent,  of  cases  after  extrac- 
tion, r.  Devcroux  Marshall  (Royal  Lon- 
don Oplithalmic  Hospital  Reports;  Uni- 
versal Med.  Journal,  Mar.,  '96). 

In  looking  over  notes  of  between  500 
and  GOO  personal  cases,  the  most  success- 
ful cataract  operations  have  been  those 
in  which  it  was  possible  to  extract  the 
lens  in  its  capsule  and  without  an  iri- 
dectomy. In  118  of  s\ich  cases  only  3 
eyes  were  lost.  The  next  best  lot  of 
cases  are  those  in  which  the  lens  was 
extracted  in  its  capsule  after  an  iridec- 
tomy; out  of  91  of  tlicse  cases  only  3 
eyes  were  lost.  B.  H.  Gimlctte  (Indian 
Lancet,  Apr.  16.  '98). 

Case  of  a  woman,  aged  35  years,  who 
was  nearly  blind.  The  right  eye  was 
undeveloped   and   there   was   a  capsulo- 


cretaceous  cataract  in  the  left  eye.  A 
very  large  flap  was  made  and  a  large 
iridectomy  was  performed  as  a  first 
operation.  Thirty-seven  days  after  the 
first  operation  the  cataract,  which  was 
found  to  be  more  capsular  than  creta- 
ceous, was  removed.  Five  years  after 
the  operation  the  patient  reads  the 
newspapers  without  glasses;  the  vision 
Vo>  and  she  wears  a  4  or  5  '/j  D.  for  dis- 
tance. E.  L.  Parks  (Boston  Med.  and 
Surg.  Jour.,  Jan.  10,  1901). 

Depression  of  the  lens  in  cataract  is 
indicated  in  some  instances  notwith- 
standing the  brilliant  results  obtained 
from  extraction  by  modern  methods. 
The  classes  of  eases  to  which  this  ap- 
plies are  those  in  which  conditions  are 
present  which  render  it  doubtful  whether 
any  operation  should  be  undertaken. 
For  example:  1.  Those  who  are  greatly 
enfeebled  by  age  and  other  infirmities. 
2.  Where  physical  obstacles  to  extrac- 
tion are  present:  e.g.,  small  palpebral 
fissures,  small  eye,  and  deeply  set  in  the 
orbit.  3.  Chronic  conjunctivitis  and  dac- 
rj-oc^'stitis.  4.  Considerable  degree  of 
deafness.  5.  In  the  insane.  6.  Chronic 
bronchitis.  7.  Fluid  vitreous,  with  tremu- 
lous iris.  8.  Where  extraction  has  been 
unsuccessfully  performed  in  one  eye.  9. 
In  the  htemorrhagic  diathesis.  Power 
(Brit.  Med.  Jour.,  Oct.  26,  1901). 

In  1000  consecutive  cataract  ex- 
tractions performed  on  864  patients, 
of  whom  130  had  both  eyes  oper- 
ated, obtained  good  results  (vision 
from  V«  to  %«)  in  89  per  cent.;  in- 
different (vision  poor,  but  sufficient 
to  enable  the  patients  to  go  about 
alone)  in  5.7  per  cent.;  failures  in 
4.5  per  cent.  Of  the  failures,  3.6  per 
cent,  were  diie  to  sepsis,  the  others  to 
intraocular  liiemorrhage.  iritis  in  2 
cases,  iridocyclitis  in  1,  and  delachetl 
retina  in  1.  Of  these  45  failures.  20  had 
been  done  with  iridectomy  and  19  with- 
out. The  indifferent  results  (5.7  per 
cent.)  were  due  to  various  causes,  such 
as  sepsis,  opaque  cortex,  iritis,  glau- 
coma, overripencss,  mercurial  cloudiness, 
vitreous  prolapse,  and  so  on.  Of  351  pa- 
tients from  whom  family  histories  were 
obtained,  in  S4,  or  nearly  24  per  cent., 
parents  and  other  relatives  had  had  eat- 


18 


CATARACT.    TREATMENT. 


aract.    ilaynard  (India  Medical  Gazette, 
Feb.,  1903)". 

Many  operators,  however,  still  make 
use  of  an  iridectomy  before  tliey  expel 
the  lens,  justly  claiming  for  this  method 
that  it  enables  them  to  get  rid  of  any 
remaining  cortical  matter  much  more 
readily.  They  also  state  that  it  prevents 
prolapse  of  the  iris  and  that  the  lens 
may  be  extruded  through  a  small^^ 
wound. 

Those  who  prefer  extraction  without 
iridectomy  urge  that  the  advantages  of 
a  round,  mobile  pupil  make  it  the  opera- 
tion of  choice.  The  contra-indications 
are:  an  unripe  cataract,  increased  intra- 
ocular tension,  a  small  rigid  pupil,  and 
an  intractable  patient. 

Despite  the  most  careful  precautions, 
prolapse  of  the  iris  does  occur  in  a  few 
case  of  simple  extraction,  usually  ap- 
pearing during  the  first  twenty-four  or 
forty-eight  hours.  If  it  be  small,  it  may 
be  let  alone.  If  it  be  considerable,  and 
the  lips  of  the  wound  remain  ununited, 
the  line  of  corneal  incision  may  be 
opened  and  the  prolapsed  portion  of  the 
iris  excised  with  an  iridectomy-scissors. 
Should  the  prolapse  occur  after  the 
wound  has  united,  it  is  best  either  to 
wait  until  about  the  tenth  day,  when  a 
formal  iridectomy  can  be  made,  or,  if 
not  productive  of  any  irritation  and  the 
pupil  is  not  much  distorted,  it  can  re- 
main undisturbed,  cicatrization  and  flat- 
tening subsequently  taking  place. 

Conclusions  readied  from  study  of  last 
70  cases  operated  for  secondary  cataract 
are  that  in  9.5  per  cent,  of  all  cases  dis- 
cission is  to  be  preferred  to  all  other 
methods  of  handlinfj  secondary  cataracts. 
In  the  70  eases  improvement  of  vision 
was  observed  in  (54,  in  5  it  remained  the 
game,  and  in  1  it  was  somewliat  reduced. 
Discission  is  justifiable,  but  there  should 
not  be  the  slightest  pulling  or  tearin,;? 
with   the   discission-needle.     The   knife- 


needle  to  cut  with,  and  an  ordinary  dia- 
cission-needle  to  fix  with,  are  the  safest 
precautions  against  secondary  glaucoma 
after  such  procedures.  Knapp  (Trans. 
Amer.  Ophth.  Soc.,  '98). 

In  certain  cases  in  which  complica- 
tions are  feared,  or  when  it  is  advisable 
to  hasten  the  maturity  of  the  cataract, 
an  iridectomy  known  as  preliminary 
iridectomj',  can  be  performed  some  time 
before  the  extraction  of  the  lens  is  made. 
If  it  is  desired  to  ripen  the  lens  after  the 
iridectomy  has  been  performed,  the  lens 
may  be  triturated  with  a  spatula  either 
directly  applied  to  the  anterior  capsule 
or  indirectly  through  the  cornea.  Rapid 
swelling  and  opacification  of  the  lens  is 
said  to  follow  these  procedures,  and  the 
extraction  in  many  cases  is  made  pos- 
sible in  several  weeks'  time  after  the 
operation.  The  lens-substance,  how- 
ever, in  these  cases  seem  to  have  obtained 
an  undue  degree  of  friability,  which 
may  be  detrimental  to  the  complete  re- 
moval of  the  lens-substance. 

Some  operators  have  adopted  the 
method  of  syringing  the  anterior  cham- 
ber after  the  removal  of  the  main  body 
of  the  lens,  in  order  to  remove  any  re- 
maining cortical  matter.  As  this  plan, 
however,  entails  the  bringing  of  another 
instrument,  which  may  be  an  additional 
source  of  infection,  into  the  eyeball,  and 
is  always  attended  by  more  or  less  local 
reaction,  its  disadvantages  seem  to  be  so 
many  that  its  employment  has  never  be- 
come general. 

Details  of  last  400  personal  operations: 
Incision  entirely  in  the  margin  of  the 
transparent  cornea,  in  a  plane  parallel 
to  that  of  the  iris,  and  with  a  small  con- 
junctival flap.  Corneal  incisions  tend  to 
be  complicated  by  adlierenee  of  the  iris 
and  by  keratitis;  more  peripheral  in- 
cisions are  disturbed  by  prolapse  of  iris 
and  cyclitis.  The  conjunctival  flap  pro- 
tects against  infection  of  the  wound:  a 
matter  of  great  importance  in  countries 


CATARACT.    TREATMENT. 


19 


where  conjunctival  and  lacrymal  affec- 
tions are  common.  The  opening  in  the 
capsule  is  made  with  a  cystotome,  be- 
hind the  upper  part  of  the  iris  near  the 
equator  of  lens,  and  is  six  or  seven  milli- 
metres in  extent.  Tlie  lens  is  expressed 
without  introducing  a  spatula;  no  in- 
strument of  traction  is  employed  even  in 
complicated  cases.  Reposition  of  the 
iris  is  made  bj'  means  of  a  sound  or 
stylet  that  is  slightly  curved.  Binocular 
bandage  is  used.  The  patient  need  not 
be  kept  in  bed.  The  dressing  is  changed 
after  twenty-four  hours,  sooner  if  neces- 
sary; minute  inspection  of  the  ej-e  and 
of  the  wound;  immediate  ablation  of 
any  prolapse  of  iris.  Knapp  (Annales 
d'Oculist.,  Oct.,  '97). 

Entire  absorption  of  cloudy  lens  or 
capsule-remains  may  often  be  accom- 
plished by  the  use  of  from  5  to  15  grains 
of  potassium  iodide  three  times  daily 
for  several  weeks  after  extraction. 
Wicherkiewicz  (Woch.  f.  Therap.  u.  Hyg. 
d'Auges,  Sept.  8,  '98). 

In  order  to  prevent  secondary  cataract, 
the  lens  is,  at  times,  removed  in  its  cap- 
sule. This  is  accomplished  by  deliver- 
ing it  by  a  spoon  or  a  loop,  after  an 
iridectomy  has  been  performed,  without 
the  performance  of  a  capsulotomy.  As 
the  operation  is,  at  times,  attended  by 
loss  of  vitreous  humor,  it  is  not  fre- 
quently employed. 

Many  of  the  accidents  occurring  dur- 
ing cataract  extraction  are  the  results  of 
want  of  skill.  In  some  instances,  how- 
€ver,  it  happens  that  the  patient's  con- 
dition is  such  that  a  successful  result 
can  scarcely  be  expected.  Deafness, 
loss  of  self-control,  and  great  stupidity 
■are  all  harmful  and  even  injurious  at 
times. 

Although  planned  with  the  utmost 
■exactness,  it  sometimes  happens  that  the 
size  of  the  lens  is  misjudged  and  the 
normal  corneal  section  is  made  too  small. 
If  tliis  occurs,  the  incision  should  be  en- 
larged by  one  or  two  clean  snips  with  a 


scissors.  Should  prolapse  of  the  vitre- 
ous humor  take  place  during  the  deliv- 
ery of  the  lens,  an  iridectomy  had  better 
be  carefully  done  and  the  lens  removed 
with  a  loop  or  a  spoon.  Prolapse  of  the 
vitreous  humor  occurring  after  the  ex- 
traction of  the  lens  is  much  less  serious 
for  the  time  being.  It  interferes,  how- 
ever, with  tire  proper  coaptation  of  the 
lips  of  the  wound  and  renders  inflam- 
matory action  more  liable,  while  in  many 
cases  it  becomes  a  most  harmful  com- 
plication for  the  future  welfare  of  the 
organ. 

Usually  there  is  some  discomfort  for 
several  hours  after  the  operation.  Should 
this  continue  and  be  at  all  marked,  the 
bandage  should  be  removed  and  the  eye 
inspected.  At  times  great  relief  will  be 
given  by  gently  pulling  down  the  lower 
eyelid  and  giving  exit  to  an  accumula- 
tion of  tears  or  by  allowing  a  faultily 
placed  eyelash  to  escape  into  proper 
position.  If  the  eyeball  appears  the 
least  injected  and  the  slightest  signs  of 
iritis  be  present,  atropine  should  be  im- 
mediately instilled  into  the  conjunctival 
cul-de-sac.  Suppuration  may  appear, 
usually  taking  place  before  the  third  or 
fourth  day,  and  is  traceable  to  infection, 
generally  from  lacrymal  disease.  In  a 
few  instances  it  is  dependent  upon  a  lack 
of  nutrition  to  the  eye.  If  it  is  due  to 
the  former,  it  is  best  combated  by  cau- 
terization of  the  edges  of  the  incision, 
the  instillation  of  sulphate  of  atropine, 
the  use  of  hot  compresses,  and  attention 
paid  to  the  general  health. 

An  eye  whose  lens  has  been  removed 
is  termed  aphakic,  and,  in  order  that  its 
vision  may  be  useful,  it  must  be  pro- 
vided witli  an  artificial  lens  correspond- 
ing in  relative  strength  to  the  crystalline 
lens  that  has  been  removed,  plus  a  cylin- 
drical one  to  correct  any  astigmatism 
resulting  from  cicatrization  of  the  cor- 


20 


CEREBRAL  ABSCESS. 


neal  incision.  To  this  artificial  lens 
must  be  added  a  convex  spherical  one  of 
two  or  three  dioptres'  strength  for  use 
during  near  work.  As  cicatrization  is 
usually  not  completed  until  four  to  six 
weeks  after  the  operation,  it  is  better  to 
postpone  ordering  glasses  until  at  least 
that  time. 

Corneal  measurements  after  extraction 
of  cataracts:  Conclusions  from  an  ex- 
amination of  59  cases: — 

1.  Two  weeks  after  the  flap-extraction 
of  cataract  there  is  corneal  astigmatism 
varying  from  1.75  D.  with  rule  to  22.0 
D.  against  rule. 

2.  The  greatest  amount  of  this  astig- 
matism disappears  in  the  following  four 
to  six  weeks. 

3.  It  is  slowly  reduced  for  six  months, 
after  which  it  seems  there  are  no  further 
changes. 

Bearing  these  facts  in  mind,  it  is  evi- 
dent that  an  accurate  estimation  of  the 
ultimate  glasses  cannot  be  made  at  the 
end  of  two  weeks.  A.  0.  Pfingst  (Ar- 
chives of  Ophthal.,  July,  '96). 

Case  of  extraction  of  cataract  in  which 
union  was  delayed  for  twenty  days.  It 
finally  took  place,  however,  with  good 
vision.  G.  C.  Harlan  (Trans.  Amer. 
Ophth.  Soc,  '98). 

Analysis  of  a  series  of  500  consecutive 
operations  for  primary  cataract,  per- 
formed between  June  22  and  November 
2,  1901,  a  period  of  nineteen  weeks,  in 
the  Government  Ophthalmic  Hospital,  at 
Madras.  All  but  30  of  these  operations 
were  done  on  the  Saturdays  of  this 
period,  making  an  average  of  27  opera- 
tions for  each  operating  day.  On  an 
average  of  from  12  to  10  patients  were 
operated  upon  in  an  hour.  In  making 
a  section  in  the  sclero-corncal  margin, 
the  author  endeavors  to  graduate  the 
section  according  to  the  size  of  the  lens. 
Each  patient  was  inspected  and  dressed 
daily  after  the  operation.  As  little  in- 
terference with  the  parts  as  possible  is 
made  after  operation.  Atropine  is  used 
as  a  routine  measure  on  the  third  morn- 
ing after  operation,  provided  there  is  no 
centra-indication;  the  sound  eye  is  un- 
bound   on    the    fifth   morning,   the   eye 


operated  upon  is  released  on  the  seventh 
day  if  all  is  going  well,  and  the  patient 
is  discharged  at  this  time  to  report  as 
an  out-patient.  Stress  is  laid  on  the 
importance  of  treating  any  complication 
that  may  be  present  prior  to  operation. 
This  applies  even  to  slight  congestion 
of  the  conjunctiva.  The  author  presents 
an  interesting  analysis  of  the  complica- 
tions and  of  the  results  obtained  in 
these  cases,  and  closes  with  the  warm 
commendation  of  McKeown's  irrigating 
apparatus, Which,  he  states,  reduced  the 
vitreous  losses  in  this  series  to  2  per 
cent.;  by  emptying  the  capsule  and 
chamber  of  debris  it  has  minimized  the 
need  for  subsequent  eapsulotomy  and 
has  enabled  the  author  to  dispense  with 
the  introduction  of  instruments  into  the 
eye  after  the  escape  of  the  nucleus;  it 
is  of  great  value  in  clearing  the  cham- 
ber of  fluid;  by  gently  and  evenly  re- 
placing the  iris,  it  has  been  most  valu- 
able and  it  has  expedited  recovery,  inas- 
much as  it  has  left  behind  so  little 
cortex  to  be  absorbed;  another  advan- 
tage which  it  possesses  is  that  of  ren- 
dering operation  possible  in  very  imma- 
ture cataracts.  Elliot  (Lancet,  Nov.  8, 
1902). 

Chaeles  a.  Oliver, 

Philadelphia. 

CATAREH,  NASAL.     See  Nasal 
Cavities. 

CATAREHAL  BRONCHITIS.     See 

BnoNCiirris. 

CATARRHAL  LARYNGITIS.     See 

Laryngitis. 


CATARRHAL 

Pneumonia. 


PNEUMONIA.       See 


CEREBELLITIS.    See  Encephalitis. 

CEREBRAL  ABSCESS. 

Definition. — Ccrcljrii]  abscess  is  a  focal 
siipjiuralive  enceplialitis  affecting  either 
the  gray  or  white  matter  or  both.  The 
abscess  may  be  single  or  there  may  be 
several  separate  foci  of  suppiirafion. 
(See,  also.  Encephalitis.) 


CEREBRAL  ABSCESS.    SYMPTOMS. 


21 


Symptoms. — The  symptoms  may  be  of 
acute  rapid  onset  or  they  may  develop 
slowly  and  insidiously  during  several 
weeks  or  even  months.  Clinically  the 
symptoms  are  divisible  into  those  which 
are  general  and  those  which  are  local  or 
focal,  the  former  being  those  of  general 
diffused  cerebral  compression  or  irrita- 
tion, the  latter  representing  perversion 
or  interruption  of  motor,  sensory,  or 
special  function,  varying  according  to 
the  anatomical  site  of  the  abscess. 
Among  the  general  symptoms  which  are 
most  common  are  headache  and  lassi- 
tude, perversion  of  the  intelligence  and 
the  emotions,  disturbances  of  sleep  and 
of  consciousness,  vertigo,  vomiting,  con- 
vulsions, and  sometimes  optic  neuritis. 
These  general  symptoms  will  vary  some- 
what in  degree  and  character,  according 
to  the  mode  of  onset.  When  the  abscess 
produces  symptoms  rapidly  the  headache 
is  more  intense;  as  a  rule,  there  is  a 
more  active  or  decided  involvement  of 
intelligence  and  consciousness,  some- 
times manifesting  itself  in  acute  delir- 
ium or  in  profound  somnolence  or  semi- 
coma; there  may  be  rigors,  with  an 
abrupt  and  decided  rise  of  temperature, 
and  the  whole  picture  suggests  an  active 
meningitis  from  which,  indeed,  it  may 
be,  and  often  is,  difficult  to  distinguish 
it.  General  convulsions  are  not  uncom- 
mon in  cases  with  acute  onset.  When 
the  symptoms  are  of  slow  gradual  devel- 
opment they  are  usually  much  less  in- 
tense in  degree.  The  headache  is  rela- 
tively mild;  the  vertigo  may  be  slight; 
vomiting  may  be  absent  or  occur  only 
rarely;  instead  of  somnolence  or  coma 
there  may  be  simple  apathy,  and  a  state 
of  simple  mental  confusion  with  irrita- 
bility may  appear  instead  of  delirium. 
The  temperature  in  such  cases  is  usually 
normal  or  subnormal;  occasionally  those 
patients  will  exhibit  periods  of  remis- 


sion attended  with  a  very  dangerous 
semblance  of  well-being  and  comfort. 
Sooner  or  later  the  disease  becomes  ag- 
gressive, and  evidences  of  focal  disturb- 
ance may  be  observed  by  which  the  site 
of  the  abscess  may  be  determined.  These 
focal  symptoms  will  vary,  as  has  been 
stated,  in  accordance  with  the  function 
of  the  brain-area  affected  by  the  abscess. 
There  are  several  methods  of  approach — 
short-cuts,  so  to  speak — to  a  considera- 
tion of  the  focal  symptoms.  Brain-ab- 
scess is  apt  to  develop  in  certain  areas 
according  to  the  cause  with  a  constancy 
which  is  of  decided  value  in  localization. 
When  due  to  an  extension  from  ear  dis- 
ease, for  example,  the  abscess  is  nearly 
always  found  in  one  of  three  localities: 
the  temporo-sphenoidal  lobes,  the  cere- 
bellum, or  the  pons-medulla  region. 
More  than  half  of  all  cases  are  located 
in  the  temporo-sphenoidal  lobes  or  the 
cerebellum.  If  the  pus  enters  through 
the  medium  of  a  secondary  phlebitis  of 
the  lateral  sinus  the  abscess  will  quite 
probably  be  found  in  the  cerebellum. 

If  the  pus  enters  the  superior  petrosal 
sinus  it  will  be  found  in  the  cerebrum 
and  probably  in  the  temporal  lobe.  When 
caused  by  trauma  the  abscess  usually 
bears  some  relation  in  its  location  to  the 
site  of  the  trauma,  though  sometimes  the 
pus-formation  is  at  a  remote  part  of  the 
brain  from  the  seat  of  injury,  as,  for  ex- 
ample, in  the  occipital  lobe,  the  blow 
having  been  received  over  the  frontal 
region. 

Cerebral  abscess,  when  due  to  necrosis 
or  disease  of  the  bones  of  the  face,  is 
frequently  located  in  the  frontal  lobes 
or  at  the  base;  when  from  syphilis  or 
tuberculosis,  its  site  is,  as  a  rule,  the 
motor  convexity,  the  base,  or  the  cere- 
bellum. Pya?mia  and  other  constitu- 
tional infections  are  apt  to  induce  multi- 
ple abscesses,  which  seem  rather  prone 


22 


CEREBRAL  ABSCESS.    SYMPTOMS. 


to  develop  in  the  distribution  of  the 
middle  cerebral  artery  of  the  left  hemi- 
sphere. The  data  of  cerebral  localiza- 
tion should  be  applied  in  determining 
the  site  of  the  abscess  in  .each  instance. 
The  principles  of  localization  in  cases  of 
uncomplicated  brain-abscess  located  in 
actiye  regions  apply  with  unusual  con- 
stancy, the  diffusion  of  symptoms  being 
less  than  in  tumor,  hemorrhage,  or  any 
other  focal  disease. 

It  should  not  be  forgotten,  however, 
that  brain-abscess  occurs  occasionally 
without  any  apparent  focal  symptoms  at 
all,  and  sometimes,  indeed,  with  very  few 
general  sjinptoms,  the  diagnosis  being  a 
post-mortem  revelation. 

Analysis  of  1G9  cases,  including  6  per- 
sonal. Of  this  number,  98  were  cases  of 
abscess  proper,  and  of  these  40  were 
located  in  the  temporal  lobe  and  31  in 
the  cerebellum.  Localizing  sjTnptoms 
were  found,  in  a  large  proportion  of 
cases,  conspicuous  by  their  absence.  As 
to  subnormal  temperature,  in  only  2 
cases  of  these  98  was  the  temperature 
below  normal.  The  most  constant  altera- 
tion of  temperature  was  a  moderate  ele- 
vation. Aphasia  was  present  in  only  6 
of  40  cases,  involving  the  temporal  lobe, 
many  of  them  on  the  left  side.  Frank 
Allport  (Jour.  Amer.  Med.  Assoc,  Oct. 
22  to  Dee.  24,  '92). 

While  in  many  cases  an  acute  abscess 
of  the  brain  may  be  diagnosed  with  some 
certainty,  a  chronic  cerebral  abscess  may 
exist  and  yet  give  no  positive  indication 
of  its  presence.  Too  often  the  condition 
is  only  discovered  by  postmortem  exami- 
nation. The  diagnostic  indications  of  a 
chronic  abscess  of  the  brain  are  few  and 
untrustworthy.  Of  first  importance 
among  such  indications  is  the  presence 
of  a  sufTieicnt  cause,  such  as  middle-ear 
disease,  local  injury,  or  caries  of  the 
cranial  bones.  Not  that  the  exciting 
cause  need  be  so  grave  as  these;  the 
absccHH  may  follow  any  of  the  specific 
fevers,  and,  as  these  occur  so  very 
frcfiuenlly  without  leaving  any  such 
gequcloe,  the  connection  may  not  be  rec- 


ognized. The  signs  of  a  chronic  cerebral 
abscess  are  few  in  number, — pyrexia, 
lieadache,  and  optic  neuritis, — but  none 
of  these  can  be  depended  on;  pyrexia 
is  often  completely  absent,  and,  as  Murri 
points  out,  in  many  cases  a  subnormal 
temperature  is  present;  the  headache,  if 
localized  and  persistent,  and  occurring 
after  one  of  the  usual  exciting  causes,  is 
suggestive,  but  nothing  more;  and  optic 
neuritis  may  equally  be  a  sign  of  a, 
tumor  or  meningitis.  Other  symptoms 
such  as  paralyses,  though  often  of  use 
in  determining  the  situation  of  a  lesion, 
are  of  no  value  in  deciding  as  to  its 
nature.  If  we  have  in  any  case  a  suf- 
ficient cause,  and  the  signs  already  men- 
tioned are  well  marked,  we  may  be  fairly 
confident  that  an  abscess  is  present,  but 
we  cannot  be  at  all  certain.  Augusto 
Murri  (Lancet,  Jan.  5,  12,  26;  Feb.  2, 
'95). 

Study  of  32  cases,  13  of  which  were 
in  children  under  one  year  of  age,  9  of 
these  being  under  six  months  and  5 
under  three  months;  3  occurred  during 
the  second  year,  and  5  each  in  the  third, 
fourth,  and  sixth  years,  no  case  being 
included  in  which  the  patient  was  five 
years  old  or  over. 

Conclusions:  In  a  large  proportion  of 
the  cases  only  general  symptoms  are 
present,  and  these  in  very  great  variety. 
Focal  symptoms  may  be  misleading  un- 
less they  are  constant;  and  even  then 
they  may  depend  upon  associated  lesions, 
s\ich  as  meningitis.  Motor  symptoms 
only  can  be  trusted,  since  the  sensory 
symptoms  are  difficult  or  impossible  to 
determine  in  infants  or  young  children. 
L.  E.  Holt  (Archives  of  Pediatrics,  Mar., 
'98). 

Report  of  2  cases  of  abscess  of  the 
brain  due  to  the  pneumococcus,  and  7 
cases  from  literature.  The  first  per- 
sonal case  occurred  some  weeks  after 
recovery  from  an  attack  of  bronclio- 
pneumonia.  Vertigo,  transitory  loss  of 
consciousness,  cramps  and  pain  in  the 
right  arm,  followed  by  contractures  and 
involuntary  movements  were  first  noted. 
Within  a  few  days  tliere  was  complete 
right  hemiplegia  and  rapid  death  from 
coma.  At  the  autopsy  slight  hepatiza- 
tion  of   the   lungs   was   found,   but   no 


CEREBRAL  ABSCESS.    DIAGNOSIS. 


23 


bronchiectasis,     suppuration,     or     gan- 
grene.   An  abscess  was  found  in  the  left 
parietal    lobe,   destroying    part    of    the 
corona  radiata,  and  extending  immedi- 
ately under  the  meninges,  which  were 
inflamed    and    suppurating.      The    pus 
from  the  abscess  contained  a  large  num- 
ber   of    Fraenkel's    diplococci,    together 
with  chains  of  streptococci.    The  second 
patient  complained  of  joint  pains,  suf- 
fered from  delirium,  and  died  within  a 
few  days  of  the  onset  of  illness.     Hepa- 
tization was  found  also  at  the  bases  of 
both  lungs.    A  small  abscess  was  found 
in  the  corona  radiata  of  the  left  hemi- 
sphere under  the  lower  part  of  the  as- 
cending parietal  convolution,  the  pus  of 
which,  as  well  as  the  meningeal  e.xudate, 
contained     Fraenkel's     diplococcus,     to- 
gether with  staphylococci  and  strepto- 
cocci.     In    only    one    of    the    9    cases 
recorded    was    the    pneumococcus    the 
only  organism  found.     Boinet   (Rev.  de 
M6d.,  Feb.  10,  1901). 
Diagnosis. — Ordinarily  it  is  quite  ap- 
parent in  patients  suffering  from  cere- 
bral abscess  that  some  affection  of  the 
brain  exists.    It  is  by  no  means  so  easy 
always  to  decide  that  the  symptoms  are 
due  to  abscess.    The  diseases  which  most 
often  confuse  the  diagnosis  are  menin- 
gitis, tumor,  and  sinus-phlebitis.     The 
difficulty  encountered  in  differentiating 
brain-abscess    from    sinus-phlebitis    and 
meningitis  is  increased  by  the  fact  that 
the  same  causes  may  operate  to  produce 
either  of  them.     This  is  especially  true 
of  trauma  and  the  various  infectious  dis- 
eases and  also  of  disease  of  the  internal 
ear,  though  the  latter  points  to  abscess 
rather  than  meningitis  or  phlebitis.     In 
all  three  the  temperature  is  affected,  but 
it  is  usually  above  normal  and  sometimes 
quite  high  in  meningitis  and  phlebitis, 
while  it  is  either  below  normal  or  quite 
irregular  in  abscess. 

Although  almost  all  observers  agree 
that  subnormal  temperature  is  the  rule 
in  brain-abscess,  it  must  not  be  depended 
upon.  Case  in  which  the  temperature 
reached  to  105°  or  lOG"  F.,  and  was  so 


irregular  as  to  suggest  pyaemia  and 
thrombosis  of  the  lateral  sinus.  Again, 
much  stress  is  laid  upon  the  presence  of 
a  cerebellar  gait,  yet  this  was  often  the 
result  of  irritation  of  the  auditory  nen-e 
or  of  irritation  of  the  semicircular  canals. 
Optic  neuritis  is  sometimes  present,  but 
not  often,  probably  because  there  was  no 
time  for  it  to  develop.  JI.  Allen  Starr 
(Med.  Rec,  Dec.  11,  '97). 

Cerebellar  abscess  may  be  distinguished 
from  labyrinthine  disease  by  its  more 
violent  headache,  its  persistence,  and  its 
location;  and  by  the  somnolence  which 
increases  from  day  to  day.  In  abscess 
of  the  temporo-sphenoidal  or  occipital 
lobes  of  the  cerebrum  there  are  motor 
affections,  paresis,  contractures,  spasms, 
but  always  on  the  side  opposite  to  that 
of  the  lesion  or  the  otitis;  and  aphasia 
and  hemianopsia  are  important  signs. 
In  glioma,  gliosarcoma,  tuberculoma, 
and  parasitic  tumors  of  the  cerebellum 
there  is  a  tendency  to  produce  other  than 
local  symptoms.  Syphilis  must  always 
be  carefully  sought  for  in  the  history. 
Dieulafoy  (Le  Progres  Mfd.,  .June  30, 
1900). 

Abscess  may  be  present  for  a  consid- 
erable time  without  giving  rise  to  any 
symptoms;  there  may  be  no  car  compli- 
cation ;    twitchings,   drowsiness,    mental 
inactivity,  which  are  often  present,  are 
apt   to   be   attributed   to   renal  disease. 
Another  symptom,  which  was  prominent 
in  personal  cases,  was  extreme  emacia- 
tion, which,  to  the  ordinary  practitioner, 
is  only  too  liable  to  suggest  only  tuber- 
culosis   or    malignant    disease.     Burnet 
(Practitioner,  June,  1903). 
In    meningitis    the    onset    is    usually 
more  acute,  the  symptoms  more  diffused, 
the  delirium   is  more  conspicuous,   the 
tendency    to    rigidity    and    generalized 
spasm  is  more  marked;   there  is  photo- 
phobia and  a  state  of  wide-spread  cuta- 
neous   hypera?sthesia    with    accelerated 
respirations   and   irregular,   high    pulse. 
Focal    symptoms   are    less  -common    in 
meningitis  e.xcept  in  cases  affecting  the 
base,  when   the  number  and  degree  of 
involvement   of  craninl   nerves   is   more 
marked  than  in  cerebral  abscess.    If  the 


24 


CEREBRAL  ABSCESS.    DIAGNOSIS. 


meningitis  is  localized  and  circum- 
scribed, I  do  not  believe  it  is  possible 
to  make  the  difYerentiation  positively. 
Tenderness  of  the  skull  over  the  site  of 
the  disease  points  to  abscess  rather  than 
meningitis  in  such  cases. 

Traumatic  brain-abscesses  may  be  con- 
founded with  traumatic  meningitis,  apo- 
plexy, encephalitis,  tumor,  epilepsy,  and 
traumatic  neuroses.  A  one-sided  trau- 
matic apoplexy  or  a  hsemorrhagic  non- 
purulent encephalitis  may,  from  symp- 
toms alone,  easily  be  taken  for  abscess. 

Suppurative  meningitis  occurring  with 
an  abscess  is  likely  to  be  overlooked. 
An  abscess  of  the  brain  is  marked  by 
normal  or  subnormal  temperatures;  fever 
is  by  no  means  a  necessary  symptom.  If 
an  attack  begins  with  a  rise  of  tempera- 
ture, it  is  probably  not  due  to  an  ab- 
scess of  the  brain,  certainly  not  to  an 
uncomplicated  one.  A  slow  pulse  is,  per- 
haps, the  most  reliable  single  symptom. 

Patients  suffering  from  ear  troubles 
often  become  hysterical,  and  a  hasty 
diagnosis  of  hysteria,  even  if  the  typical 
symptoms  are  present,  may  falsely  be 
made  in  cerebral  abscess  of  the  otitic 
origin.  Oppenheim  (Fortschritte  der 
Med.,  Nov.  15,  '90). 

Symptoms  of  brain-abscess  due  to 
middle-ear  suppuration  based  on  195 
cases.  It  occurs  most  frequently  in 
early  middle  life.  Out  of  175  cases  in 
which  the  sex  was  stated,  122  were 
males  and  only  53  were  females.  In 
181  cases  of  temporo-sphenoidal  abscess 
85  occurred  in  the  right  hemisphere  and 
90  in  the  left.  Tlie  variations  in  the 
temperature  show  no  characteristic 
feature,  normal  or  subnormal,  a  slight 
or  even  a  considerable  rise  being  vari- 
ously observed,  the  complications,  such 
as  meningitis  or  sinus-phlebitis,  account- 
ing for  these.  The  uncomplicated  must 
be  separated  from  the  complicated  be- 
fore positive  deductions  can  be  drawn. 
The  temperature  variations  noted  in  170 
cases  were:  Normal,  40;  elevated,  100; 
subnormal,  18.  In  cases  of  uncompli- 
cated brain-absccHH  tlie  temperature  is 
raJBcd  in  about  one-half.  Chills  are  not 
frequently  noted.    The  most  frequent  of 


the  cerebral  symptoms  is  headache, 
which  was  present  in  103  cases.  Stiff- 
ness of  the  neck  was  noted  12  times, 
and  general  convulsions  10  times.  Gen- 
eral headache  is  valueless  as  a  sign,  but 
localized  headache  and  tenderness  are  of 
some  diagnostic  importance.  It  seldom 
declares  itself,  however;  in  28  cases  it 
was  on  the  same  side  as  the  abscess, 
while  in  14  other  cases  tenderness  in  tue 
temporal  region  of  the  same  side  was 
complained  of.  Disturbance  in  cerebra- 
tion occurred  in  more  than  one-half  of 
the  cases.  Mental  symptoms  were  rare, 
and  the  sensory  disturbances  ranged 
from  a  slight  form  of  slow  cerebration 
to  loss  of  consciousness  and  coma,  which 
occurred  in  74  cases.  Even  heavy  stupor 
did  not  adversely  influence  operative 
procedure.  The  pulse  was  slowed  in  73 
instances.  In  GO  cases  changes  in  the 
fundus  were  noted. 

As  to  localized  cerebral  symptoms, 
aphasia  occurred  53  times  in  a  total  of 
90  abscesses  of  the  left  temporo-sphe- 
noidal lobe.  Hemianopsia  was  met  mth 
0  times.  Motor  disturbances  on  the  op- 
posite side,  whether  of  the  nature  of 
paralyses  or  as  unilateral  convulsions, 
were  noted  in  70  cases.  Hammerachlag 
(Monats.  f.  Ohrenh.,  Jan.,  1901). 

The  principle  employed  in  the  urethro- 
scope and  other  instruments  for  illumi- 
nating cavities  applied  to  an  instrument 
devised  by  tlie  writer,  i.e.,  the  "encepha- 
loscopc,"  by  means  of  which  one  is  able 
to  readily  diflerentiate  between  an  acute 
and  chronic  brain  abscess.  The  clinical 
value  of  the  instrument  is  threefold. 
One  can  determine  accurately:  (1) 
wlictlicr  an  abscess-cavity  is  completely 
cviicuatcd,  (2)  tlie  presence  of  bands  of 
adhesions  which  obstruct  drainage,  and 
(3)  whether  the  abscess-cavity  is  acute 
or  chronic.  The  differentiation  is  made 
on  tlie  difference  in  tlie  appearance  of 
tlic  walls  of  the  cavities,  which  the 
author  describes  at  length.  Wliiting  (In- 
tcrnat.  Jour.  Surg.,  8ci)t.,  1003). 

In  sinus-phlebitis  the  swelling  back  of 
the  ear  with  tenderness  on  pressure  and 
a  cord-like  hardness  of  the  jugular  at 
times  will  determine  the  nature  of  the 


CEREBRAL  ABSCESS.    ETIOLOGY. 


25 


condition  with  little  difficulty.  Within 
the  past  year  lumbar  puncture  has  found 
some  favor  as  a  means  of  differentiating 
abscess  from  meningitis  and  sinus- 
thrombosis.  If  the  fluid  withdrawn  is 
clear  and  does  not  contain  micro-organ- 
isms the  disease  is  probably  meningitis. 
Excess  of  leucocytes  also  indicates  men- 
ingitis. The  diagnostic  value  of  lumbar 
puncture  is,  however,  exceedingly  prob- 
lematical as  yet,  and  promises  to  remain 
60,  in  the  opinion  of  the  writer,  so  far  as 
brain-abscess  is  concerned,  for  a  very  in- 
definite future. 

Most  of  the  cerebral  complieationa  ob- 
served occur  in  connection  with  chronic 
cases  of  suppurative  otitis  media.  One 
should  be  chary,  however,  about  making 
a  diagnosis  of  brain-abscess  in  these  cases 
on  the  first  appearance  of  cerebral  symp- 
toms; it  is  better  to  watch  the  case  for 
two  or  three  days  before  deciding,  as  not 
infrequently  apparently  serious  cerebral 
symptoms  gradually  disappear  as  a  free 
discharge  from  the  ear  is  established. 

Above  and  back  of  the  car  is  the 
region  of  the  brain  concerned  in  the 
storage  of  the  memories  of  the  sounds 
of  words.  If  this  part  of  the  brain  is 
injured,  the  person  becomes  unable  to 
understand  what  is  said  to  him.  Again, 
everything  that  we  call  to  mind  by  our 
visual  sense  employs  the  function  of  the 
occipital  lobe  of  the  brain:  the  visual 
centres.  The  connection  between  the 
hearing-centres  in  the  temporal  lobe  and 
the  visual  centres  in  the  occipital  lobe 
is  made  by  a  long  tract  lying  under  the 
cortex  of  the  brain:  a  distinct  associa- 
tion-tract. When  this  tract  is  destroyed, 
as  it  often  is  in  abscess  of  the  temporal 
lobe,  if  one  ask  such  a  person  what  some 
object  is  that  is  held  up  before  him,  he 
recognizes  the  object,  but  cannot  call  it 
to  mind  and  name  it,  because  of  the 
destruction  of  this  jissociation-tract. 
This  peculiar  lack  of  association  is  an 
important  symptom  to  elicit  in  cases  of 
suspected  abscess  of  the  temporal  lobe, 
yet  it  is  not  commonly  mentioned  in 
te.\t-books.  M.  Allen  Starr  (Jlcd.  Rec, 
Dec.  11,  '97). 


Conclusions  that  in  children  the  rapid 
progress,  fever,  and  a  history  of  injury 
or  otitis  generally  make  a  diagnosis  from 
tumor  easy.  In  the  slower  cases,  in 
which  there  is  little  or  no  fever,  valuable 
assistance  may  be  obtained  from  lumbar 
puncture. 

From  acute  meningitis  the  diagnosis 
is  more  difficult,  and  in  the  cases  in 
which  there  are  only  terminal  symptoms 
tlie  diagnosis  is  impossible.  In  the  more 
protracted  eases  the  distinctive  points 
with  reference  to  abscess  are  the  slower 
and  more  irregular  course  and,  as  a 
rule,  a  lower  temperature.  L.  E.  Holt 
(Archives  of  Pediatries,  Mar.,  '98). 

In  a  case  of  pycemia  of  the  sinuses 
accessory  to  the  brain,  or  with  a  history 
of  trauma  with  rapid  loss  of  flesh  and 
strength,  the  presence  of  a  high  tempera- 
ture for  a  period  of  seventy-two  hours, 
followed  by  a  decline  in  temperature 
and  an  increase  in  the  rapidity  of  the 
pulse,  with  pronounced  flexure  of  the  ex- 
tremities, progressive  increase  in  the 
dilation  of  the  pupils,  a  half-unconscious 
condition  with  uncontrollable  restless- 
ness, peculiar  indisposition  of  the  pa- 
tient to  obey  requests,  the  presence  of 
sugar  in  the  urine,  slow  respirations, 
tendency  when  standing  to  go  toward 
one  side,  or  swinging  of  the  hands  always 
toward  one  side,  and  the  entire  absence 
of  paralysis,  comprises  a  set  of  symptoms 
indicative  only  of  abscess  within  the 
cerebellum.  L.  J.  Hammond  (Archives 
of  Pediatrics,  June,  '99). 

The  symptoms  of  brain  abscess  divided 
into  three  groups:  1.  Symptoms  due  to 
deep-seated  suppuration.  2.  SjTuptoms 
due  to  increased  intracranial  pressure. 
3.  Focal  symptoms.  The  surgeon  sees 
only  those  cases  in  which  the  diagnosis  is 
easy  and  the  results  are  good,  while  the 
neurologist  sees  all,  the  doubtful  and  the 
fatal  cases,  and  is  not  quite  so  sanguine 
as  to  results.  Hoppe  (.Jour.  Amer.  Med. 
.\ssoc..  Mar.  14.  1903). 

Etiology. — Abscess  of  the  brain  is 
always  a  secondary  condition  dependent 
upon  the  intracranial  invasion  of  micro- 
organisms from  adjacent  or  remote 
sources  of  infection.     Anv  one  of  the 


26 


CEREBRAL  ABSCESS.    ETIOLOGY. 


pus-producing  micro-organisms  may  act 
as  an  exciting  cause.  The  atTection  may 
occur  at  any  age,  but  is  most  frequently 
observed  in  adolescence  and  middle  adult 
life.  It  is  rare  in  very  young  children 
(Holt)  and  in  old  age.  Males  are  more 
often  affected  than  females  in  propor- 
tions varying  from  3  to  1  to  5  to  1  ac- 
cording to  the  observer.  By  far  the  most 
frequent  source  of  infection  is  purulent 
disease  of  the  middle  or  internal  ear. 
More  than  a  third  of  all  cases  originate 
from  this  source  (Pitt).  Cerebral  ab- 
scess is  far  more  common  from  chronic 
than  from  acute  suppurative  disease  of 
the  ear.  This  fact  has  been  established 
beyond  question  by  an  analytical  study 
of  several  thousand  cases  (Jansen). 

It  was  formerly  admitted  that  the 
development  of  an  otitic  abscess  neces- 
sarily implied  a  pre-existing  chronic 
suppuration  of  the  ear.  To-day,  how- 
ever, it  is  known,  from  cases  observed 
during  the  recent  epidemics  of  influenza, 
that  cerebral  abscess  may  develop  after 
an  acute  suppuration  of  the  ear.  Mon- 
nier   (La  Presse  M6d.,  Nov.  6,  '95). 

More  than  one-half  of  all  cases  orig- 
inate from  aural  disease.  The  statistics 
of  .Jansen,  who  found,  in  an  aural  clinic 
in  Berlin,  abscess  only  in  the  proportion 
of  1  case  to  20.50  cases  of  acute  otitis, 
and  1  to  400  of  chronic  suppurative 
otitis,  are  misleading.  Abscess  is  twice 
as  frequent  in  adults  as  in  children.  As 
to  Hessler's  statement  that  three-fourths 
of  all  fatal  cases  of  otitis  present  puru- 
lent pachymeningitis,  it  is  found  that  in 
less  than  one-fourth  of  these  cases  is 
there  any  direct  communication  apparent 
between  the  tympanum  and  the  extra- 
dural abscess,  mierobic  migration  having 
taken  place  through  microscopic  avenues. 
Taking  119  cases  of  true  encephalic  ab- 
Bcess,  analysis  shows,  with  reference  to 
localization,  82  in  the  middle  lobe,  24  in 
the  cerebellum,  4  in  both  cerebrum 
and  cerebellum,  3  in  the  pons,  2  in 
the  occipital  lobe,  and  1  each  in  the 
frontal  lobe  and  cerebelbir  peduncle. 
Cerebellar  abscesH   is   more   frequent   in 


adults  than  in  children,  in  whom  the 
location  is  almost  exclusively  in  the 
temporo-sphenoidal  lobe.  Picque  and 
Ferrier  (Annales  des  Mai.  de  I'Oreille 
du  Larynx,  du  Nez,  etc.,  Dec,  '92). 

Statistics  upon  cerebral  abscess  follow- 
ing disease  of  the  ear  based  on  100  cases 
personally  observed,  91  being  examined 
after  death;  in  9  the  abscess  was  opened 
during  life.  The  frequency  of  such  ab- 
scesses in  the  cerebrum  is  nearly  twice 
as  great  as  in  the  cerebellum;  in  chil- 
dren below  ten  years  of  age  their  fre- 
quency is  three  times  that  of  adults, 
this  difference  being,  perhaps,  the  greater 
distance  of  the  tympanum  from  the  cere- 
bellum in  children.  The  liability  of 
males  is  twice  that  of  females,  and  the 
generally  admitted  fact  of  the  disease 
being  more  common  on  the  right  than  on 
the  left  side  is  borne  out  by  statistics. 
As  regards  the  extension  to  the  brain 
from  the  diseased  teinporal  bone,  (1)  the 
cerebral  abscess  most  often  occurs  where 
the  dura  is  implicated,  in  cases  of  dis- 
ease of  the  petrous,  or  mastoid;  (2)  the 
dura  and  brain-substance  between  the 
diseased  bone  and  the  abscess  are  gener- 
ally diseased ;  in  only  6  out  of  90  cases 
was  tlie  intermediate  brain-substance 
normal.  More  careful  observation  may 
show  more  cases  of  direct  extension  of 
the  suppuration  from  the  diseased  bone 
than  is  now  thought  to  be  the  case. 
Otto  Korner  (Archiv  f.  Ohrenheilkunde, 
vol.  xxix,  '90). 
Next  most  common  cause  of  brain- 
abscess  is  trauma  of  the  face  or  skull. 
Practically  all  cases  occurring  in  very 
young  children  are  due  to  one  of  these 
two  causes. 

Rt\idy  of  32  cases,  13  of  which  were 
in  diildrcn  under  one  year  of  age,  9  of 
tlieae  being  under  six  months  and  5  un- 
der three  months;  3  occurred  during  the 
second  year,  and  5  each  in  the  third, 
fourth,  and  sixth  years,  no  case  being 
included  in  which  the  patient  was  five 
years  old  or  over. 

Conclusions:  1.  Abscess  of  the  brain 
in  children  under  five  years  is  rare. 

2.  The  principal  causes  are  otitis  and 
traumatism. 

3.  It  rarely  follows  acute  otitis,  but 


CEREBRAL  ABSCESS.     ETIOLOGY. 


27 


most  often  neglected  eases,  and  is  usually 
secondary  to  disease  of  the  petrous  bone. 

4.  In  tlie  cases  occurring  in  infancy 
without  evident  cause,  the  source  of  in- 
fection is  probably  the  ears,  even  though 
there  is  no  discharge. 

5.  The  development  of  abscess  after  in- 
jury to  the  head  without  fracture  of  the 
skull  is  extremely  rare.  In  nearly  all 
the  traumatic  cases  definite  cerebral 
symptoms  shows  themselves  within  the 
first  two  weeks  after  the  injury.  In 
cases  with  falls  as  remote  as  several 
months,  there  is  probably  some  other 
cause,  such  as  a  latent  otitis.  L.  E. 
Holt  (Archives  of  Pediatrics,  Mar.,  '98). 

Among  adults  surgical  diseases  of  the 
ethmoid  bone,  the  orbit,  the  antrum, 
necrosis  of  the  maxillary  bones  and 
sometimes  caries  of  the  teeth,  disease  of 
the  frontal  sinus,  and  pyogenic  affec- 
tions of  the  nose  and  throat  are  occa- 
sional sources  of  intracranial  pus-infec- 
tion. Several  cases  have  occurred  as 
complications  in  erysipelas  of  the  face 
or  scalp.  Suppurative  adenitis  of  the 
cervical  glands  is  another  well-known 
source  of  infection.  Pus-accumulations 
anywhere  in  the  system — even  in  remote 
localities,  as  the  liver,  the  lungs,  the 
Fallopian  tubes,  etc. — may,  by  circula- 
tory metastasis,  be  attended  with  a  com- 
plicating cerebral  abscess. 

Sudden  death  of  a  soldier  who  wag 
considered  to  be  in  perfect  health,  the 
autopsy  showing  a  multiple  abscess  of 
the  left  frontal  lobe.  The  man,  at  the 
time  of  his  death,  was  reclining  on  a 
bench,  reading  a  newspaper.  A  few 
weeks  previously  he  had  received  a  gun- 
shot flesh-wound  of  the  arm,  in  an  en- 
gagement with  robbers,  which  had  healed 
readily,  the  bone  not  having  been  in- 
jured. The  abscess  was  evidently  sec- 
ondary to  the  injury  of  the  arm,  though 
not  a  single  symptom — mental  or  phys- 
ical— suggested  its  presence.  Surgeon 
Turner,  U.  S.  A.  (N.  Y.  Med.  Jour., 
Mar.  14,  '91). 

The  brain  may  be,  and  often  is,  at- 


tacked  in   general   pysemia   and   septi- 
ca:;mia,    and    tuberculosis    and    syphilis 
affecting  the  encephalon  may  present  the 
local  conditions  of  abscess.    Various  con- 
stitutional diseases  of  infectious  origin, 
among  which  may  be  mentioned  small- 
pox, typhus  and  typhoid  fevers,  grippe, 
and  cerebrospinal  meningitis  are  occa- 
sionally complicated  with  brain-abscess. 
Three   eases   of   abscess   in   the  right 
cerebral  hemisphere,  all  occupying  nearly 
the  same  position  in  the  centrum  ovale, 
all  attended  with  left  lateral  homony- 
mous hemianopsia,  with  great  weakness 
of    the   left   arm   and   leg,   the   loss    of 
power  being  greater  in  the  leg  than  in 
the   arm,  the  face  escaping  almost  en- 
tirely, and  with  sensory  impairment  on 
the  left  side.     The  infective  material  in 
two  was  probably  derived  from  distant 
suppuration,  and  in  one  from  an  injury 
of    the    scalp   although    the    incomplete 
post-mortem   examination    renders    this 
uncertain.    J.  T.  Eskridge  (Med.  News, 
July  27,  '95). 

Two  cases  of  metastatic  abscess  of  the 
brain  from  primary  actinomycosis  of  the 
lungs.  Both  cases  were  considered  clin- 
ically to  be  of  tuberculous  origin.  C.  H. 
Martin  (Jour,  of  Path,  and  Bact.,  Nov., 
'94). 

Aphasia  during  convalescence  after 
evacuation  of  brain-abscess.  Dr.  Jack's 
case  corroborates  the  view  of  Broca  and 
Trousseau,  who  first  maintained  that 
there  is  no  writing-centre  in  the  sense 
of  a  centre  in  which  are  stored  up  the 
kinesthetic  memories  of  written  words 
and  capable  of  stimulation  independ- 
ently of  Broca's  convolution.  The  in- 
ability to  write  in  this  case  was  abso- 
lutely coincident  with  the  inability  to 
talk.  When  the  auditory  centre  either 
failed  to  recall  the  memory  of  the  sound 
of  the  word,  or,  if  rememliered,  failed 
to  convey  the  stimulus  properly  to  the 
kinesthetic  speech-centre,  it  failed  also 
to  communicate  it  to  the  centre  for  the 
movements  of  the  hand.  That  the  centres 
and  fibres  affected  were  not  destroyed 
is  shown  by  the  complete  recovery.  G.  L. 
Walton  (Boston  Med.  and  Surg.  Jour., 
Dec.  26,  1901). 


28 


CEKEBRAL   ABSCESS.     PATHOLOGY  AND  JIORBID  ANATOMY.     PROGNOSIS. 


Pathology  and  Morbid  Anatomy. — 
Brain-abscess  is  always  secondary  to  the 
intracranial  invasion  of  pyogenic  micro- 
organisms. The  growth  of  such  abscess 
is  steadily  progressive  except  when,  as 
occurs  occasionallj',  a  membranous  wall 
of  tissue  develops,  inclosing  the  pus 
and  preventing  its  encroachments  upon 
surrounding  structures;  when  so  sur- 
rounded, the  abscess  is  said  to  be  of  the 
incapsulated  variety.  'WTien  incapsula- 
tion  occurs  the  further  progress  of  the 
disease  is  temporarily  and  sometimes  for 
long  periods  of  time  arrested.  The  dan- 
ger of  rupture  is  always  present,  how- 
ever, such  rupture  resulting  in  sudden 
apoplectiform  symptoms  with  death,  the 
picture  simulating  a  sudden  vascular 
lesion.  In  its  incipiency  brain-abscess 
presents  the  local  appearance  of  what 
has  been  termed  "acute,  red  softening." 
Later  the  pus  changes  from  a  reddish- 
yellow  to  a  greenish  or  greenish-yellow 
color,  and  is  at  times  quite  offensive  in 
odor  when  exposed.  The  complications 
usually  found  are  sinus-  phlebitis  and 
thrombosis  (lateral  and  superior  petro- 
sal), leptomeningitis,  extensive  meningo- 
encephalitis, and  purulent  pachymenin- 
gitis. Leptomeningitis  and  sinus-throm- 
bosis are  especially  common  in  cases  due 
to  aural  disease. 

Charcot  and  Leyden  crystals  found  in 
pus  from  cerebral  abscess.  These  crys- 
tals have  been  found  in  the  expectora- 
tion of  asthmatics,  the  foeces  of  antcraics, 
from  the  AncJiiilostnmum  duodenale,  in 
the  semen,  in  bone-marrow,  and  in  other 
conditions.  So  far,  they  seem  to  have  no 
constant  Bip:nificance.  Campbell  (Med. 
Chronicle,  Feb.,  '94). 

The  streptothrix  found  in  a  case  of 
abseesB  of  the  brain  characterized  dur- 
ing life  by  epileptiform  attacks.  This 
streptothrix  developed  well  in  different 
culture-media,  though  only  completely 
on  potato.  In  the  primary  pus  and  in 
the  potato  culture  it  presented  the  form 


of  ramifying  filaments  with  knob-like 
terminations.  It  stained  well  by  Gram's 
method.  Inoculated  into  the  guinea-pig 
it  did  not  prove  pathogenic.  Inoculation 
into  a  rabbit  caused  diffusion  of  the 
parasite  in  the  organism  without  phe- 
nomena of  reaction  or  of  pseudotubercu- 
losis. Ch.  F6r6  and  Faguet  (Le  Bull. 
M6d.,  Aug.  25,  '95). 

Infection  may  spread  from  the  tym- 
panic cavity  in  four  directions:  (1) 
upward  through  the  vault,  (2)  outward 
through  the  external  table  of  the  proc- 
ess, (3)  downward  mainly  through  the 
lower  wall  of  the  mastoid  cells,  and  (4) 
backward  along  the  groove  of  the  mas- 
toid sinus.  Infection  spreads,  not  only 
through  necrotic  perforations,  but  also 
along  the  lymph-  and  blood-vessels  of 
the  osseous  canaliculi.  An  unusual 
mode  is  through  the  groove  of  the  trans- 
verse sinus  and  the  foramen  lacerum 
posterius.  Quervain  (Sem.  M6d.,  Aug. 
20,  '97). 

Case  of  neglected  middle-ear  disease  in 
which  a  large  necrotic  focus  was  found 
immediately  beneath  the  groove  for  the 
attachment  of  the  tentorium,  midway 
between  the  hiatus  Fallopii  and  the 
aqueductus  vestibuli,  communicating 
with  a  focus  in  the  left  side  of  the  cere- 
bellum. Bacteriological  and  histological 
examination  revealed  the  staphylococcus 
pyogenes  albus,  staphj'lococcus  cereus 
flavus,  and  the  bacterium  vulgare  (pro- 
teus  vulgaris).  A.  P.  Ohlmacher  (Cin- 
cinnati Lancet-Clinic,  Sept.  4,  '97). 

Prognosis.  —  Brain-abscess  is  almost 
always,  if  not  always,  inevitably  fatal  if 
treated  otherwise  than  surgically.  The 
duration  is  variable.  The  acute  cases 
generally  terminate  within  a  week  or  ten 
days  in  death.  The  slow  incapsulated 
variety  may  extend  over  months  and 
even  years,  the  patient  dying  finally  from 
exhaustion  or  perhaps  siiddonly  from 
rupture  of  the  abscess-sac. 

Analysis  of  109  cases  in  which  pus 
in  some  form  was  present  in  the  brain; 
only  11  recoveries  occurred,  all  of  which 
were  operative  cases.  In  10  other  cases 
the  pus  was  evacuated,  cither  by  opera- 


CEREBRAL  ABSCESS.    TREATMEXT. 


29 


tion  or  spontaneously.  Every  case  not 
operated  upon  died,  while  more  than  50 
per  cent,  of  those  in  which  the  skull  was 
trephined  recovered.  This  emphasizes 
forcibly  the  imperative  necessity  for 
operative  interference  in  all  cases  of 
cerebral  abscess.  Frank  Allport  (.Jour. 
Amer.  Med.  Assoc,  Oct.  22  to  Dec.  24, 
'92). 

The  prognosis  of  cerebral  abscess  due 
to  ear  disease  after  operation  is  not  as 
good  as  might  be  expected,  because  these 
abscesses  are  not  infrequently  multiple 
(20  per  cent.)  and  on  account  of  the 
difficulty  in  making  a  correct  diagnosis. 
A  number  of  these  abscesses  run  a  latent 
course.  Occasionally  the  sj-mptoms  are 
few  and  of  a  passing  character.  Again, 
the  patient  is  sometimes  seen  in  the  last 
stages  of  the  disease,  when  the  abscess 
has  burst  through  to  the  surface  of  the 
brain  or  into  the  ventricles.  Even  when 
the  patient  has  been  under  observation 
in  hospitals  diagnostic  mistakes  are  pos- 
sible. ^Mien  the  abscess  is  accompanied 
by  other  intracranial  complications  a 
correct  diagnosis  may  be  out  of  the 
question.  Grunert  (Berl.  klin.  Woch., 
Dec,  '96). 

The  course  of  an  otitic  cerebral  ab- 
scess is  regularly  acute  or  subacute.  In 
many  cases  pus  opens  into  the  ventricles 
or  on  the  meninges  after  some  days  or 
weeks,  and  proves  fatal.  It  is  not  rare, 
however,  that  the  course  is  slow  and 
that  the  purulent  formation  ceases,  and 
the  virulence  of  the  infection  may  then 
be  so  light  that  a  limiting  wall  will  form. 
If  the  cerebral  tissue  surrounding  the 
abscess  is  in  nearly  a  normal  condition, 
absorption  can  occur.  The  membrane 
limiting  the  purulent  focus  may  undergo 
calcareous  degeneration.  Roepke  (La 
Trat.  MCd.,  .June  15,  1900). 

Prognosis  based  on  statistics  of  195 
cases  of  brain-abscess  due  to  middle-ear 
disease,  180  of  which  warrant  the  fol- 
lowing conclusions:  Out  of  106  cases  in 
which  the  brain  was  explored  through 
the  squamous  temporal,  40,  or  37.7  per 
cent.,  recovered.  Of  64  that  were  ex- 
plored through  the  mastoid  region,  31, 
or  48.4  per  cent.,  recovered.  Of  10 
cases  in  which  the  brain  was  exposed, 
both    through    the    tegmen    nntri    and 


through  the  squamous  temporal,  8,  or 
80  per  cent.,  recovered.  Hammerschlag 
(Monats.  f.  Ohrenh.,  Jan.,  1901). 

E.xamination  of  the  fundus  shows  that 
in  intracranial  suppuration  following  ear 
disease  neuritis  or  choked  disk  is  rare, 
unless  a  combination  of  suppurative  foci 
exist.  From  a  prognostic  point  of  view, 
changes  in  the  papilla  are  of  no  value. 
As  a  rule,  there  is  a  distinct  retro- 
gression of  the  inflammation  several 
days  after  the  pus  has  been  evacuated. 
But  even  if  it  should  persist  or  increase, 
the  outlook  is  no  less  favorable.  0. 
Kerner  (Deutsche  Arch.  f.  klin.  Med., 
vol.  Ixxiii,  1902). 

Every  brain  case  should  be  explored 
where  the  symptoms  are  focal  regard- 
less of  the  supposed  pathological  lesion. 
H.  C.  Gordinier  (Amer.  Jour,  of  Insan- 
ity, Jan.,  1903). 

Treatment. — Every  case  of  brain-ab- 
scess should  be  operated  upon  and  the 
pus  evacuated  just  as  soon  as  the  diag- 
nosis can  be  made.  In  no  department 
of  brain-surgery  have  results  been  so 
brilliantly  successful.  In  a  great  major- 
ity of  cases  the  abscess  is  easily  accessible 
and  can  be  readily  reached.  The  sur- 
geon should  not  wait  for  coma  or  grave 
symptoms  of  irritation  or  pressure,  but 
should  enter  the  cranial  cavitj',  at  least 
in  an  exploratory  way,  as  soon  as  it  seems 
probable  that  cerebral  symptoms  in  a 
given  case  point  to  abscess-formation. 

In  trephining  after  traumatic  brain 
affection  it  is  advisable  to  distinguish 
late  and  early  cerebral  abscess.  The  late 
abscess  apparently  does  not  arise  in  tlie 
contused  part  itself,  but  in  a  healthy 
one,  just  like  non-traumatic  abscesses 
after  traumatic  suppuration  in  the  bones 
and  soft  parts.  These  late  abscesses  gen- 
erally lie  deep,  and  are  covered  by  nor- 
mal cerebral  cortex.  The  early  abscesses 
usually  arise  in  the  injured  area,  into 
which  infective  material  penetrates  from 
without.  Fatal  meningitis  is  often  asso- 
ciated with  immediate  suppuration.     If 


30 


CEREBRAL  ABSCESS.     TREATJVIENT. 


the  suppurative  process  is  slower,  how- 
ever, and  the  wound  in  the  brain  small, 
adhesions  of  the  cerebral  membranes 
take  place  in  the  region  of  the  injury, 
and  abscesses  may  result.  These  ab- 
scesses are,  to  a  certain  extent,  the  re- 
sult of  retention  of  pus  in  the  nests  and 
sacs  of  a  deep  wound,  and  are  generally 
superficial  and  cortical.  They  do  not 
develop  before  two  weeks.  Very  early 
onset  of  paralysis  or  s3'mptoms  of  irrita- 
tion are  rather  signs  of  meningitis,  while 
the  late  appearance  of  symptoms  points 
rather  to  abscess.    (Nasse.) 

Details  of  sixty-seven  mastoid  opera- 
tions. Most  of  them  were  done  in  the 
usual  method  of  Sehwartze,  but  the  later 
cases,  to  the  number  of  about  a  dozen, 
were  done  by  Stacke's  method  of  dis- 
secting off  the  auricle  and  soft  tissues 
of  the  canal  and  laying  them  forward, 
chiseling  away  the  posterior  bony  wall 
and  anterior  wall  of  the  attic,  so  as  to 
throw  meatus,  attic,  antrum,  and  tym- 
panum proper  into  one  open  and  visible 
cavity,  then  replacing  the  soft  parts  and 
transplanting  a  flap  of  canal-lining  into 
the  antrum.  In  these  methods  radical 
removal  of  all  diseased  structures  is  at- 
tempted, yet  in  such  an  open  manner 
as  to  rob  the  operation  of  many  of  its 
gravest  dangers;  important  structures 
can  be  more  surely  avoided,  healing  is 
likely  to  be  greatly  expedited,  and  the 
recovery  should  be  secured  with  a  condi- 
tion far  less  likely  to  relapse  into  cho- 
lesteatoma or  other  renewed  troubles. 
Panse  (Therap.  Gaz.,  Apr.  15,  '92). 

In  opening  the  skull  for  cerebral  ab- 
scess the  surgeon  need  not  be  always 
anxious  about  replanting  the  bone  re- 
moved, considering  that  in  three  cases 
the  gaps,  without  replantation,  were 
soundly  filled  up, — more  so  than  in  some 
cases  in  which  the  replantation  had  been 
practiced.  In  order  to  drain  the  septic 
abscesHes  replantation  had  been  imprac- 
ticable, hut  the  result  was,  nevertheless, 
a  sound  restoration  of  the  bony  case. 
Kushton  Parker  (Liverpool  MedieoChir. 
Jour.,  Jan.,  '9.5). 

At  the  present  time  it  is  possible  to 


reach,  and  to  deal  successfully  with,  the 
following  conditions:  1.  Abscess  in  the 
cerebrum,  especially  in  the  temporo- 
sphenoidal  lobe.  2.  Abscess  in  the  cere- 
bellum. 3.  Purulent  formations  at  the 
base  of  the  skull:  (a J  extradural  ab- 
scess; (bj  subdural  abscess.  4.  Infective 
thrombosis  of  the  sigmoid  sinus,  even 
when  secondary  foci  may  exist. 

In  all  these  conditions  it  is  essential 
to  explore  the  cavities  of  the  middle  ear 
by  removing  the  outer  wall  of  the  an- 
trum. The  partitions  of  the  roof  and 
sigmoid  groove  separating  the  middle 
ear  from  the  temporo-sphenoidal  lobe 
above  and  from  the  sigmoid  sinus  be- 
hind are  the  two  great  pathways  by 
which  infective  matter  effects  its  en- 
trance into  the  interior  of  the  cranium. 

In  operating,  the  path  of  invasion 
should  be  systematically  followed  up, 
and  this  may  be  done  with  safety  and 
with  efficiency  by  means  of  the  rotary 
burr  propelled  by  a  dental  engine. 
Thomas  Barr  (Archives  of  Otology,  vol. 
xxiv,  Nos.  3  and  4). 

Case  of  abscess  of  the  temporo-sphe- 
noidal lobe  opened  and  drained  through 
the  osseous  auditory  meatus. 

The  advantages  of  this  method  of  oper- 
ating are  obvious:  In  the  first  place, 
we  get  good  and  efficient  drainage  from 
below.  The  drainage-tube  can,  if  neces- 
sary, be  kept  in  position  for  months 
without  any  discomfort.  It  can  easily 
be  removed  and  replaced,  and  there  is 
no  danger  of  not  again  finding  the  ab- 
scess-cavity. We  can  also  at  the  same 
time  cffieiently  treat  and  cure  the  attic 
and  mastoid  cells,  which  in  these  cases 
are  nearly  always  affected,  and  thus  pre- 
vent any  recurrence  of  the  disease.  Only 
one  incision  and  only  one  operation  are 
necessary.  The  operation  and  after- 
treatment  are  more  difficult  and  tedious 
than  in  the  ordinary  metliod  of  trephin- 
ing, but  the  results  are  certainly  more 
satisfactory.  Adolph  lironner  (Brit. 
Med.  Jour.,  Aug.  21,  '97). 

In  children  a  study  of  thirty-two  cases, 
no  case  being  included  in  which  the  pa- 
tient was  five  years  old  or  over,  led  to 
the  conclusion:  that  on  account  of  the 
great  amount  of  shock  attending  brain- 
surgery  in  very  young  children,  an  oper- 


CEREBRAL  ABSCESS. 


CEREBRAL  H/EMORRHAGE. 


31 


ation  should  not  be  urged  unless  definite 
localizing  symptoms  are  present,  the 
principal  one  being  hemiplegia.  L.  E. 
Holt  (Archives  of  Pediatrics,  Mar.,  '98). 

In  cerebral  operations  a  large  area  of 
the  skull  should  be  removed.  It  both 
enables  us  to  examine  the  brain  better 
when  exposed,  and  also,  if  benefit  is  to 
be  obtained  from  relief  of  cerebral  pres- 
sure, it  surely  increases  that  chance ;  and 
also  it  scarcely  increases  the  danger  of 
the  operation.  E.  D.  Fisher  (N.  Y.  Med. 
Jour.,  Apr.  16,  '98). 

Delay  in  operating  until  the  appear- 
ance of  unequivocal  localizing  symptoms, 
or  recourse  merely  to  opening  of  the 
mastoid  when  it  may  be  reasonably  as- 
sumed that  cerebral  abscess  exists,  is  a 
far  greater  injustice  to  the  patient  than 
his  subjection  to  an  exploratory  trephin- 
ing of  the  cranium.  Collins  (Amer.  Jour, 
of  Med.  Sci.,  Apr.  '99). 

It  is  important  to  determine  the  na- 
ture of  the  micro-organism  producing 
the  abscess  at  as  early  a  period  as  pos- 
sible. A  large  opening  in  the  skull 
recommended  after  first  turning  down 
a  large  scalp-flap.  For  the  drainage  of 
an  abscess  in  the  temporo-sphenoidal 
lobe  the  trephine  opening  should  be 
made  Vs  inch  above  the  suprameatal 
spine.  In  operating  for  a  cerebellar 
abscess  the  trephine  should  be  placed 
with  its  upper  edge  just  below  Reid's 
base-line  and  its  anterior  edge  touching 
the  posterior  border  of  the  mastoid 
process.  In  incising  the  dura  mater  the 
opening  should  be  made  by  a  flap  rather 
than  by  a  crucial  incision.  The  use  of 
a  long,  narrow,  straight  bistoury  recom- 
mended for  the  exploration  rather  than 
the  use  of  the  exploring  needle  or  can- 
nula, as  the  incised  wound  of  the  brain 
heals  better  than  the  punctured  wound. 
The  finger  is  also  to  be  used  for  ex- 
ploration. Irrigation  of  an  abscess  of 
the  brain  should  only  be  resorted  to 
when  tliere  is  free  exit  for  the  fluid, 
such  as  is  accomplished  by  the  use  of  a 
tube.  Tamponing  these  cavities  with 
gauze  is  not  approved.  Recurrence  of 
symptoms,  especially  in  cerebellar  ab- 
scess, is  not  an  uncommon  thing  a  few 
days  after  the  opening  of  a  brain- 
abscess,  and  it  is  duo  either  to  a  reac- 


cumulation  of  the  fluid  or  el.se  to  an 
entirely  new  formation  of  pus  in  an- 
other part  of  the  same  lobe.  C.  A.  Bal- 
lance   (Lancet,  May  25,  '1901). 

Wm.  Broaddus  Phitchard, 

New  York 

CEREBRAL  HEMORRHAGE. 

Definition.  —  Under  this  head  are 
classed  all  cases  where  there  is  an 
ell'usion  of  blood  due  to  the  rupture 
of  some  vessel  within  the  substance  of 
the  brain  proper  or  in  the  pia.  This 
htemorrhage  usually  starts  in  the  brain, 
but  may  force  its  way  out  and  become 
subarachnoidal  or  ventricular.  Except 
in  case  of  accidents,  it  rarely  makes  its 
way  into  the  subdural  space. 

The  dural  system  of  arteries  is  quite 
distinct,  and  bleeding  from  this  source 
should  be  considered  separately. 

Simple  tingeing  of  fluids  about  the 
brain,  not  coming  from  any  blood-focus, 
does  not  constitute  a  cerebral  hjemor- 
rhage  in  the  strict  sense. 

Varieties. — It  is  customary  to  classify 
these  cases  according  to  the  part  of  the 
brain  that  is  the  seat  of  the  hagmorrhage 
as  cortical,  subcortical,  or  of  the  central 
ganglia;  frontal,  or  of  either  lobe,  pon- 
tile, cerebellar,  etc.  Besides  the  above, 
however,  there  are  several  subforms, 
as: — 

Ingravescent. — This  is  a  term  ap- 
plied to  large  effusions  developing 
slowly, — i.e.,  for  a  period  of  several 
hours  or  for  a  day  or  two.  Tliis  form 
is  largely  observed  in  haemorrhage  at  the 
externa]  capsule;  the  peculiarity  is 
owed,  first,  to  rupture  of  a  large  per- 
forating artery  that  passes  up  at  tliis 
point,  and,  secondly,  to  the  parallel 
course  of  tlie  nerve-fibres  in  this  tract 
whereby  they  continue  to  separate  as  the 
pressure  increases. 

Symmetrical.  —  Here  there  is  a 
double  hfrmorrhage,  starting  from  corre- 


32 


CEREBRAL  ILEMORKHAGE.     SYIMPTOMS. 


spending    points    of    the    two    hemi- 
spheres. 

Meningeal  and  Ventricular.  — 
These  forms  may  either  start  as  such — 
though  rarely — or  they  may  start  from 
vessels  in  the  brain-substance  and  then 
rupture  through  into  one  or  the  other  of 
these  spaces. 

Traumatic. — Due  to  violence  or  in- 
jury, in  contradistinction  to  the  general 
run  of  spontaneous  cases. 

Punctate  and  Capillary. — These 
are  sufficiently  explained  by  the  terms. 
Of  themselves  they  are  rarely  of  suffi- 
cient moment  to  be  of  other  than  patho- 
logical interest. 

Symptoms. — Prodeomata.- — The  so- 
called  premonitory  symptoms  include 
headache,  dizziness,  pallor  or  flushing 
of  the  face,  fullness  in  the  head,  flicker- 
ing before  the  eyes,  visual  obscuration, 
poor  sleep,  tinnitus  aurium,  thickness 
of  the  tongue,  numbness  or  peculiar 
tinglings  of  one  side  of  the  body,  heavi- 
ness of  extremities,  slight  mental 
changes, — as  lapses  of  memory,  drowsi- 
ness, and  irritability, — changed,  slowed, 
or  intermittent  pulse,  etc.  These,  when 
occurring  in  an  elderly  person,  are 
thought  by  many  pliysicians  to  point 
to  an  impending  haemorrhage.  There 
is  no  doubt  that  such  symptoms  fre- 
quently precede  thrombosis.  This  fact, 
together  with  the  lack  of  adequate 
pathological  proof  and  inability  to  ac- 
count for  premonitions  in  htemorrhage, 
has  caused  a  disinclination  among  con- 
servative observers  to  recognize  any  con- 
nection of  the  kind.  In  some  cases, 
however,  there  may  be  a  preliminary 
oozing  sufTicient  to  produce  slight  symp- 
toms. Further  the  evidence  of  a  vaso- 
motor influence  suggests  that  a  local 
paralysis  of  vessels  with  sufTicient  dila- 
tation to  irritate  the  adjacent  tracts  may 
precede  the  actual  rupture.    This,  how- 


ever, in  a  few  days  ends  in  a  frank  at- 
tack of  apoplexy.  In  the  aged  most  of 
these  symptoms  point  rather  to  throm- 
bosis; but  in  earlier  years  they  may 
give  warning  of  incipient  haemorrhage. 

Constipation  is  common  in  the  pro- 
dromal stage,  but  is  too  usual  a  matter 
to  have  any  diagnostic  significance. 
Turgidity  of  the  vessels  of  the  head, 
severe  pain  in  the  head,  convulsive 
twitehings  of  an  extremity  (Jacksonian), 
unilateral  chorea,  etc.,  are  rare,  and  be- 
long to  the  initial  stage  of  apoplexy — or, 
of  course,  more  often  its  later  stages. 

Onset. — The  symptoms  that  may  mark 
the  onset  of  the  attack  include  the  vari- 
ous prodromata  just  mentioned;  also 
faintness  or  general  prostration,  convul- 
sive movements,  aphasia,  paralysis,  stu- 
por and  even  unconsciousness,  free  per- 
spiration; slow,  tense  pulse,  etc. 

The  regularity  and  the  sequence  with 
which  these  appear  are  very  variable. 
In  fulminant  attacks  the  severest  symp- 
toms may  promptly  develop,  and  even 
death  itself  be  not  long  delayed.  Sud- 
den death  may  occur  if  the  trouble  is  in 
the  pons.  Oftener  there  is  a  gradual  in- 
crease, both  in  the  number  and  the  se- 
severity  of  the  manifestations,  for  some 
little  time:  one,  two,  three,  or  more 
hours. 

Headache. — Very  often  there  is  no 
special  complaint  of  pain  in  the  head, 
and  again  headache  has  been  such  an 
habitual  thing  with  the  patient  that  lit- 
tle importance  can  be  attached  to  it. 
Nephritic  complications,  when  present, 
tend  also  to  rob  this  symptom  of  value. 

In  many  cases,  however,  there  is  head- 
ache, severe,  deep,  and  general  in  char- 
acter, less  often  localized.  It  becomes 
more  pronounced  as  the  effusion  in- 
creases in  volume,  and,  even  when  the 
consciousness  has  become  more  or  less 
oliscured,  the  sufTcrcr  may  persist  in  put- 


CEREBRAL  HiEMORRHAGE.    SYMPTOMS. 


33 


ting  a  hand  to  the  head,  evidently  be- 
cause some  degree  of  pain  or  distress  is 
still  perceived.  When,  therefore,  we 
meet  a  headache  unusual  to  the  patient, 
excruciating  in  character,  not  otherwise 
explicable,  and  associated  with  suggestive 
phenomena,  it  acquires  some  value  as  a 
symptom. 

A  low,  occipital  pain  is  common  in 
cases  of  cerebellar  apoplexy;  but  as  it 
may  be  due  to  other  causes  its  only  sig- 
nificance comes  from  association. 

Vomiting. — This  is  a  common  symp- 
tom and  one  of  much  clinical  impor- 
tance, its  value,  however,  depending 
much  on  the  certainty  with  which 
urffimia  can  be  excluded.  Nausea  may, 
of  course,  attend  dizziness,  faintness,  or 
thrombosis;  but  actual  vomiting,  aside 
from  urtemia  (especially  if  the  person  is 
reclining),  argues,  in  a  suspicious  case, 
for  haemorrhage.  This  applies  to  the 
increasing  period  of  the  effusion. 

[It  has  been  claimed  to  be  especially 
frequent  in  cerebellar  htemorrhage,  but, 
as  stated,  it  is  common  in  all  forms.  W. 
Browning.] 

Where  the  latter  is  at  all  voluminous, 
in  almost  any  part  of  the  brain  we  see 
vomiting,  often  severe  and  even  some- 
what prolonged.  Its  occurrence  depends 
upon  the  volume  of  the  effusion,  the 
speed  with  which  it  is  poured  out,  and 
to  some  extent  upon  its  location.  In 
the  slower,  or  ingravescent,  forms,  even 
though  they  finally  reach  a  large  size, 
there  is  less  tendency  to  emesis.  It  is 
where  we  find  other  evidence  of  an 
apoplectic  seizure  that  this  symptom  ac- 
quires value;  then  it  also  assists  mate- 
rially in  differentiating  the  nature  of  the 
brain-process. 

Nearly  always  some  other  plausible 
explanation  is  proffered:  the  person  has 
just  eaten  overheartily,  been  lying  in  a 
cramped  position,  had  an  hypodermic. 


taken  medicine  that  upset  the  stomach, 
or  been  suffering  from  gastric  catarrh. 
The  diagnostician  must,  of  course,  be 
able  to  discount  such  suggestions. 

Yawning  and  Sighing.  —  These  are 
very  frequent  and  striking  symptoms  in 
haemorrhage,  and  are  often  more  marked 
if  the  patient  is  in  a  sitting  position. 
There  is  a  slight  parallelism  between 
them  and  the  vomiting.  But  as  they  are 
also  common  in  cases  of  thrombosis  and 
may  occur  in  embolism  while  there  is  a 
badly  damaged  heart,  they  have  only  a 
limited  diagnostic  value.  In  cases  of 
haemorrhage  these  manifestations  sug- 
gest that  the  focus  has  already  reached 
a  sufficient  size  to  produce  some  degree 
of  brain-anasmia. 

Coma  and  Other  Disturbances  of  Con- 
sciousness.— These  are  of  great  impor- 
tance for  both  the  positive  and  the  dif- 
ferential diagnosis.  But  at  the  same 
time  they  are  matters  most  difficult  to 
describe  or  define  with  exactness  and  in 
accordance  with  the  facts. 

Coma  is  a  state  of  profound  uncon- 
sciousness not  due  to  sleep,  syncope,  or 
drugs.  But  in  practice  we  meet  all  kinds 
and  degrees  of  disturbance  of  conscious- 
ness. The  eyes  may  be  open  and  staring, 
yet  the  person  fail  to  make  any  responses 
to  our  interrogations  and  evidently  fail 
to  have  any  understanding  of  language 
or  surroundings.  More  often  there  is  a 
condition  of  stupor  that  admits  of  but 
partial  and  temporarj'  recognition.  "We 
can  then  conveniently  distinguish  coma, 
stupor  (a  partial  coma:  "semicoma- 
tose"), and  dazed  conditions. 

The  duration  of  these  states  is  next  in 
importance.  They  may  be  of  such  tran- 
sitory nature  as  to  pass  unnoticed,  or  they 
may  last  several  hours  or  days,  the 
lighter  degrees  being,  of  course,  as  a 
rule,  of  shorter  duration.  The  time  in 
the  attack  when  coma  supervenes  is  also 


34 


CEREBRAL  H.EMOREHAGE.    SYMPTOMS. 


to  be  notedj  if  at  the  start  it  may  be 
partly  a  direct  shock-effect;  if  later  and 
more  gradual  it  indicates  that  the  ef- 
fusion has  reached  a  large  volume. 

The  size  of  the  output  requisite  to 
produce  this  symptom  varies  much  with 
its  location.  A  small  clot  in  the  pons, 
for  instance,  will  produce  a  much  deeper 
impression  on  consciousness  than  one  of 
far-greater  size  in  the  pallium.  Wer- 
nicke and  others  have  sought  to  explain 
this  by  the  smaller  size  of  the  vessels, 
their  indirect  course,  and  hence  slower 
leakage  in  the  hemispheres.  But  this 
view  is  negated  by  several  facts,  how- 
ever well  it  may  explain  the  favorite 
sites  of  hasmorrhage. 

[A  competent  medical  friend  offers  the 
following  more  scholarly  definition; 
"Coma  is  a  condition  of  profound  un- 
consciousness, the  result  of  injury,  dis- 
ease, or  some  form  of  intoxication."  But 
the  sleep  of  chloral  or  morphine  is  not 
termed  coma,  while,  on  the  other  hand, 
that  of  alcoholism  often  is.  Neither  is 
true  coma  always  so  profound.  In  fact, 
there  seems  to  be  a  considerable  latitude 
in  the  use  of  this  term. 

Perhaps  the  above  definition  might  be 
modified  as  follows:    Coma  is  a  state  of 
unconsciousness  due  to  some  other  cause 
than  sleep  or  syncope.    The  cfTects  of  in- 
toxications,   soporifics,    or    anjEsthetics 
should   only   be   called   coma   when   the 
person  can  no  longer  be  roused  to  con- 
sciousness.    W.  Browning.] 
The  comparison  of  a  large  number  of 
these  cases  shows  that  involvement  of 
the  sensory  tracts  has  little  or  no  influ- 
ence on  consciousness,  while  other  cases 
with  equal-sized  foci  involving  certain 
parts  of  the  motor  path  show,  as  a  rule, 
very  marked  impairment  of  conscious- 
ness.   From  a  psychological  stand-point 
this   seemingly   anomalous   fact   agrees 
with   conclusions   based    on   other   evi- 
dence.   But  it  is  cited  here  to  prove  that 
much  depends  on  the  part  involved  as 
to  the  effect  on  consciousness. 


A  close  analogy  can  also  be  drawn 
with  cases  of  embolism.  The  writer  has 
shown  that  embolism  involving  only 
parts  above  the  basal  ganglia  does  not 
cause  coma.  Inasmuch  as  in  many  of 
these  eases  a  large  patch  of  brain-tissue 
is  involved,  and  as,  further,  the  sudden- 
ness of  the  attack  must  be  equal,  what- 
ever the  part  involved,  it  follows  that 
here  again  much  must  depend  on 
the  particular  structures  included,  for 
smaller  infarctions,  if  only  they  involve 
the  ganglia,  often  do  bring  on  coma. 

It  can  consequently  be  stated  that, 
whatever  accessory  influences  there  may 
be,  there  are  but  two  important  govern- 
ing factors  in  the  development  of  coma: 
the  size  of  the  hfemorrhage  and  the 
particular  part  of  the  brain  implicated. 
These  deserve  a  little  further  considera- 
tion. 

As  to  the  amount  of  hemorrhage  that 
will  of  itself  cause  coma,  experiments  on 
animals  by  Pagenstecher,  von  Schulten. 
and  others  have  led  to  the  conclusion 
that  in  the  human  being  one  and  a  half 
to  two  ounces  is  about  the  extent  of 
limitation  of  the  brain-space  that  can 
be  borne  without  interruption  of  psy- 
chical functions.  (More  can  be  tolerated 
in  a  diffuse  effusion  like  a  meningeal 
hcemorrhage  than  in  a  confined  focus.) 
The  exact  amount  thrown  out  in  a  case 
of  apoplexy  is  rarely,  if  ever,  known, 
since  some  of  the  fluid  is  promptly  ab- 
sorbed or  scattered,  and,  independent  of 
that,  it  is  impossible  to  more  than  esti- 
mate the  volume  of  these  irregular  foci. 
So  far  as  such  rough  estimation  goes,  it 
corresponds  fairly  with  the  experimental 
results.  This  applies  to  cases  in  the 
hemispheres  (pallium).  Wlien  the  size 
of  an  effusion  is  stated  to  be  that  of  a 
hen's  egg,  it  may  be  considered  to  equal 
two  ounces  of  fluid.  Uence,  haemor- 
rhage of  that  bulk  should  be,  and  in 


CEREBRAL  HEMORRHAGE.    SYMPTOMS. 


35 


practice  is  found  to  be,  on  the  border- 
line. It  may  be  expected  to  at  least 
produce  stupor  and  frequently  some 
coma.  When  of  greater  volume,  coma 
very  generally  results.  In  the  basal 
ganglia,  however,  a  much  smaller 
amount  may  suffice. 

The  principle  here  is  that  the  effusion, 
by  its  volume,  exerts  such  a  general  press- 
ure on  the  whole  cortex  as  to  obtund 
consciousness.  Of  the  sufficiency  of  this 
factor  there  is  no  question.  It  may  act 
by  producing  an  anaemia  or  by  more 
direct  mechanical  effect.  Further,  a 
compression,  before  ineffective,  may  be- 
come sufficient  if  the  arterial  pressure 
sinks. 

As  to  the  susceptibility  of  different 
parts,  injury  below  the  oblongata  {i.e., 
in  the  cord)  does  not  cause  coma.  The 
syncope  of  shock  or  even  sudden  death 
may  result,  but  not  real  coma.  And  it 
is  uncertain  whether  hsmorrhage  of  the 
oblongata  has  much  tendency  to  pro- 
duce coma;  most  such  cases  are  small 
and  any  stupor  is  masked  by  respiratory 
and  other  phenomena.  In  the  old  case 
of  Fabre  (quoted  by  Gintrac  and  others) 
some  loss  of  consciousness  attended  a 
small  htemorrhage  of  the  left  p)Tamidal 
body.  But  in  several  other  cases  of  small 
effusion  in  other  parts  of  the  oblongata 
no  distinctly  comatose  condition  has  de- 
veloped. 

At  the  other  brain-pole — i.e.,  corticad 
of  the  central  ganglia — we  have  already 
seen  that  coma  is  essentially  a  conse- 
quence of  general  brain-compression. 
In  this  major  portion  of  the  encephalon 
there  is  little  difference  between  the  vari- 
ous parts.  Apparently  the  occipital  lobe 
tolerates  infringement  better  than  the 
frontal  and  parietal  lobes;  but  there  is 
no  decisive  difference. 

Regarding  the  cerebellum,  the  general 
opinion  agrees  with  the  evidence  that 


uncomplicated  hasmorrhage  when  mod- 
erate in  amount  does  not  invoke  coma. 
But  in  these  rather  rare  cases  either 
rupture  occurs  or,  if  much  size  is  at- 
tained, there  is  so  much  pressure  on  sub- 
jacent structures  as  to  obscure  the  bear- 
ing of  the  case. 

There  still  remains  the  region  of  the 
central  ganglia,  the  cerebral  crura,  and 
the  pons.  Hasmorrhage  of  the  caudate 
nucleus  is  prone  to  bring  on  coma.  That 
in  the  lenticular  nuclei  and  in  the  thai- 
ami  is  somewhat  less  apt  to  do  so.  When 
in  a  cerebral  crus,  there  is  commonly 
some  coma  or,  at  least,  stupor,  though 
these  hfemorrhages  are  rarely  volumi- 
nous. Those  of  the  pons  are  most  in- 
clined to  cause  coma,  though  usually 
small  unless  they  have  already  ruptured. 
A  comparison  of  this  last  group  of  cases 
(involving  the  brain-stem)  brings  out 
forcibly  one  fact  already  referred  to, — 
viz.:  that  haemorrhages  in  the  sensory 
path  show  but  little  tendency  to  cause 
coma,  while  those  in  the  motor  path 
have  a  marked  tendency  in  that  direc- 
tion. This  fact  stands  out  quite  as 
clearly  when  they  are  compared  by  vol- 
ume. It  is,  of  course,  not  certain 
whether  this  applies  specially  to  the  mo- 
tor tract  or  to  other  and  less  under- 
stood tracts  closely  associated  with  them; 
it  may  be  fibres  to  the  so-called  somoes- 
thetic  area.  So  far  as  this  coma-zone 
has  been  noticed  in  the  past,  it  has  been 
thought  to  depend  upon  the  fact  that 
here  were  grouped  fibres  passing  to,  and 
thus  influencing  all  parts  of,  the  brain. 

Secondary  Factors  in  the  Causation  of 
Coma. — There  are,  of  course,  various 
other  influences  that  affect  this  result. 
The  person's  susceptibility  is  one;  car- 
bonic-acid poisoning  due  to  superficial 
respiration  is  another.  But  most  im- 
portant of  these  is  the  rapidity  with 
which  the  effusion  occurs.     On  the  ex- 


36 


CEREBRAL  HEMORRHAGE.    SYjVH'TOMS. 


perimental  side  it  is  well  known  that 
the  effect  on  consciousness  depends 
somewhat  on  the  rapidity  with  which  the 
compression  is  produced.  But  it  is  rare 
in  clinical  work  to  meet  cases  where  a 
hasmorrhage  has  taken  place  with  any 
such  rapidity  as  in  the  average  experi- 
ment. As  Liddel  long  ago  pointed  out, 
considerable  time  is  taken  up  before  the 
bleeding  stops.  We  also  know  that  in 
the  slow,  ingravescent  form,  though  a 
day  or  two  elapse  in  the  process,  coma 
just  as  certainly  supervenes  when  the 
volume  of  the  focus  becomes  adequate. 

The  disappearance  of  coma  is  attrib- 
uted to  a  re-establishment  of  the  cir- 
culatory balance,  to  reduction  of  press- 
ure from  lessened  cerebrospinal  fluid, 
and  perhaps  a  gradual  tolerance  to  the 
focus.  The  shock-efllect  passes  off,  and 
some  of  the  fluid  of  the  focus  is  ab- 
sorbed. 

Aphasia. — This  symptom,  of  itself  and 
without  corroborative  manifestation,  is 
rarely  indicative  of  cerebral  htemor- 
rhage.  A  considerable  majority  of  all 
cases  of  aphasia  are  due  to  other  causes 
(see  article  on  Aphasia,  vol.  i).  These 
are  mostly  transient  forms  lasting  from 
a  few  hours  to  a  few  days  and  embracing 
all  degrees  of  speech-impairment  up  to 
its  complete  loss.  They  are  occasioned 
by  gout,  urffimia,  and  less  frequently 
other  toxic  conditions.  Possibly  the 
standard  writers  do  not  take  sufficient 
notice  of  these  transient  forms.  Even 
of  the  more  lasting  cases  a  certain  num- 
ber will  be  due  to  thrombosis,  embolism, 
etc. 

Only  in  a  part  of  the  cases  of  cerebral 
haemorrhage  do  aphasic  symptoms  ap- 
pear. To  produce  these  the  speech- tract 
must  either  be  directly  injured  by  the 
effusion  or  indirectly  implicated  by 
pressure.  This,  of  course,  only  occurs 
when,  in  right-handed  persons,  the  lesion 


is  on  the  left  hemisphere,  and  in  left- 
handed  in  the  right  hemisphere.  Ap- 
parent exceptions  to  this  rule  occur  as 
in  a  recent  case  (of  embolism)  where 
an  originallj'-left-handed  youth  had  so 
trained  himself  that  he  passed  for  a 
right-handed  person. 

All  degrees  and  forms  of  aphasia  oc- 
cur in  association  with  hemorrhagic 
apoplexy.  AVhere  it  is  due  to  implica- 
tion and  not  to  direct  involvement  of 
the  speech-centre  or  tract,  then  recovery 
from  this  symptom  may  occur,  the  time 
required  and  the  extent  of  recovery  be- 
ing dependent  on  the  circumstances  of 
the  case.  By  speech-centre  we,  of  course, 
mean  not  only  the  motor  centre  in 
Broca's  convolution,  but  also  the  hear- 
ing-centre and  other  associated  parts. 
Inasmuch  as  all  forms  of  aphasia  and 
paraphasia  are  involved,  it  is  not  prac- 
ticable to  enter  on  a  discussion  of  them 
here. 

Convulsions,  Tivitcliings,  etc. — Earely 
a  few  spasmodic  twitches  occur  during 
the  onset-period  in  the  territory  where 
paralysis  is  developing.  These  may  not 
be  noticed  unless  in  the  face.  It  is  not 
certain  that  they  point  to  a  cortical 
focus. 

Quite  distinct  from  these  are  the  uni- 
lateral clonic  convulsions  (Jacksonian 
type)  that  occur  in  the  rare  cases  of 
efi'usion  about  the  cortical  motor  area. 
Such  cases  are  far  oftener  of  traumatic 
than  of  spontaneous  origin. 

Of  course,  urasmic  convulsions  may 
bring  on  or  accompany  an  apoplectic 
sei7Aire,  though  this  is  unusual.  Other- 
wise general  convulsions  in  this  condi- 
tion point  strongly  to  ventricular  hoem- 
orrhage  or  to  rupture  into  the  lateral 
ventricles. 

[Tlipy  filfio  are  not  rare  in  thrombosis, 
and  in  both  moninpoal  and  frontal 
lioomonhagcs.    W.  Buowninc] 


CEREBRAL  H.EMOREHAGE.    SYMPTOMS. 


37 


Even  in  case  of  such  rupture,  how- 
ever, convulsions  do  not  always  follow; 
nor  does  slight  oozing,  as  in  many  cases 
of  impending  rupture,  have  this  effect. 
When  such  convulsions  do  occur,  they 
may  be  of  the  severest  character  that  we 
ever  witness.  In  any  case,  such  com- 
plications give  a  very  bad  outlook,  for 
ventricular  rupture  is  only  more  cer- 
tainly and  rapidly  fatal  than  uraemia. 
Rigidity  of  the  paralyzed  or  even  both 
sides  is  also  frequent  in  ventricular 
rupture. 

Paralysis  ;  Respiratory  Paresis. — This 
is  one  of  the  commonest  as  well  as  most 
striking  and  characteristic  symptoms, 
although  not  a  necessary  accompani- 
ment. It  may  affect  either  motion  or 
sensation  or  both. 

The  time  of  the  attack  at  which  it 
develops  depends  on  the  location  and  the 
rapidity  of  development  of  the  efEusion. 
Usually  it  appears  with  the  onset  of  the 
seizure,  though  at  first  frequently  but 
a  mild  degree  of  paresis;  in  such  a  case 
we  can  conclude  that,  as  yet,  the  motor 
path  is  only  suffering  from  pressure.  In 
occasional  cases  the  paralysis  is  not  man- 
ifest until  later  or  becomes  pronounced 
only  in  the  reaction-stage;  but  it  is  then 
difficult  to  distinguish  from  an  increas- 
ing effusion. 

Motor  involvement  constitutes  the 
most  marked  and  important  manifesta- 
tion of  average  cases,  and  when  present 
may  range  all  the  way  from  the  slightest 
degree  of  weakness  up  to  complete  flac- 
cidity.  ^^^lile  any  of  tlie  voluntary  mus- 
cles may  suffer,  certain  prevalent  types 
can  be  made  out.  Monoplegias  and  more 
limited  paralyses,  running  as  such  from 
the  start,  occur  in  some  of  the  rare  cases 
of  ha3morrhage  corticad  of  the  internal 
capsule.  When  this  is  in  the  occipital, 
frontal,  or  temporal  lobes,  there  may  be 
no   definite   paralysis  unless   the  focus 


becomes  so  large  that  the  transmitted 
pressure  affects  the  motor  neurons.  But, 
as  the  great  majority  occur  in  the  basal 
ganglia  or  pons,  the  hemiplegic  type  is 
by  far  the  most  common.  Of  this  there 
are  two  distinct  forms:  the  one  of  sim- 
ple hemiplegia,  where  all  the  affected 
parts  are  on  one  side  (arm,  leg,  and  face, 
all  or  in  part),  and  the  other  of  crossed 
hemiplegia,  where  an  arm-and-leg  pa- 
ralysis on  one  side  is  associated  with  some 
involvement  of  the  cranial  motor  tracts 
on  the  other  side.  This  latter  form  is 
typical  of  localization  in  the  pons,  be- 
cause of  the  fact  that  the  cranial  tracts 
have  already  decussated,  while  the  first 
form  is  that  due  to  the  common  site  in 
the  basal  ganglia.  In  the  very  rare  cases 
of  bleeding  in  a  cerebral  crus,  there  may 
be  a  special  form  of  crossed  paralysis: 
involvement  of  the  arm  and  leg  on  the 
side  opposite  the  lesion  and  oculomotor 
paralysis  on  the  same  side,  due  to  the 
intimate  relationship  of  this  nerve  with 
the  cms. 

There  is  some  basis  for  the  view  that 
lesions  of  the  thalamus  may  present  a 
special  characteristic.  This  consists  of 
loss  of  emotional  or  pantomimic  move- 
ments, while  the  volitional  motions  are 
still  preserved.  This  applies  specially  to 
the  cranial  distribution.  If,  on  the  con- 
trary, the  cranial  paralysis  is  due  to 
lesions  more  anterior  at  the  same  level 
or  higher  up  there  may  be  a  preserva- 
tion of  the  so-called  mimic,  with  a  loss 
of  voluntary,  movement.  In  practice, 
haemorrhages  of  this  region  are  usually 
so  massive  that  both  grades  of  motion 
are  equally  lost. 

It  is  possible  that  something  of  the 
kind  also  holds  for  the  extremities,  since 
we  sometimes  see  cases  of  hemiplegia 
where,  in  sleep,  the  patient  is  able  to 
lift  a  hand  to  the  head.  Here  may  also 
be  classed  the  so-called  methemiplegic 


38 


CEREBRAL  H-^MOREHAGE.    SYMPTOMS. 


movements;  these  are  such  as  occur  in 
a  paralj'zed  part  in  association  with  vol- 
untary movements  in  the  corresponding 
well  part. 

In  ordinary  hemiplegia  ,we  find  the 
arm  and  leg  motionless  or  nearly  so,  a 
little  motion  possibly  remaining  in  the 
fingers  or  toes.  The  arm  lies  helpless 
by  the  side  or  across  the  chest.  The  pa- 
tient, if  requested  to  move  it,  reaches 
over  with  the  other  hand.  The  leg  stays 
in  almost  any  position  in  which  it  is 
placed.  In  the  complete  form  it  is  im- 
possible for  the  patient  to  turn  in  bed 
or  to  rise  at  all  from  the  recumbent 
position.  In  coma  the  paralysis  may  be 
presumed  from  the  drawn  face,  expi- 
ratory puffing  of  one  cheek,  and  the 
heavier,  passive  drop  of  the  affected  arm 
when  lifted  and  let  go. 

As  a  rule,  the  leg  improves  faster  than 
the  arm,  perhaps,  as  claimed,  because 
the  arm-tract  is  apt  to  be  more  involved 
than  the  leg,  or,  perhaps,  because  the 
leg-movements  (as  in  walking)  are  more 
automatic  in  character.  It  is  consid- 
ered an  unfavorable  omen  when,  on  the 
contrary,  the  arm  improves  faster  than 
the  leg.  The  hypoglossal  and  facial 
tracts  are  more  apt  to  escape  direct  im- 
plication, and  the  upper  facial  quite  reg- 
ularly escapes  (a  point  of  distinction 
from  like  hysterical  paralysis). 

Sensory  loss  is  also  a  common  though 
less  frequent  and  lasting  accompaniment 
than  motor.  In  many  cases  it  is  so 
transient  that  in  a  few  days  little  trace 
of  it  remains.  Its  occurrence  depends 
on  interference  with  the  sensory  neu- 
rons. Their  most  exposed  point  is  at 
the  carrefour  smsitif  (posterior  border  of 
the  internal  capsule),  where  the  sensory 
tracts  are  more  closely  grouped  than 
elsewhere  in  their  course.  This  point 
)B  also  about  opposite  the  commoner 
sites  of  haBmorrhage,  though  a  little  to 


one  side,  which  harmonizes  with  the 
fact  that  permanent  loss  of  sensation  is 
the  exception.  The  most-marked  feat- 
ures of  this  type  are  loss  of  common 
sensation  in  the  opposite  half  of  the  body 
and  homonymous  hemianopsia  (blind- 
ness of  opposite  half  of  visual  field  of 
each  eye).  Hearing  may  also  be  inter- 
fered with  and  sometimes  taste  and 
smell,  the  latter  two  only  on  the  opposite 
side.  In  hemorrhages  involving  either 
the  hearing-centre  in  the  first  temporal 
gyre,  the  visual  centre  in  the  cuneus, 
the  other  sensory  centres,  or  the  paths 
connecting  these  with  paxts  below,  there 
will  be  a  correspondingly-limited  loss 
of  sensation.  In  pons  lesions  the  special 
senses  escape,  unless  occasionally  those 
of  hearing  or  equilibrium.  At  the  same 
time  the  tracts  for  general  sensation  to 
the  other  side  of  the  body  may  sufEer. 
In  cases  where  there  is  more  lasting 
anaesthesia  it  involves  deep  parts  and 
mucous  membranes  as  well  as  the  sur- 
face. 

Eye-symptoms.  —  Pupillary  changes 
have  but  little  value  here  for  purposes 
of  localization.  They  do,  however,  serve 
one  important  and  usually  overlooked 
purpose:  the  presence  of  anisocoria  (in- 
equality of  the  pupils)  is  valuable  ob- 
jective evidence  of  the  existence  of  some 
real  lesion,  and  has  a  bearing  on  differ- 
ential diagnosis.  Of  course,  this  pre- 
supposes the  existence  of  corroborative 
symptoms  and  the  recent  acquisition  of 
the  inequality.  The  possibility  of  latent 
anisocoria  should  be  excluded  by  deter- 
mining whether  the  condition  persists 
on  full  illumination  of  the  two  eyes;  if, 
on  so  testing,  the  pupils  become  equal, 
the  inequality  can  be  put  down  as  proli- 
ably  an  affair  of  long-standing  or  spinal 
in  origin. 

Tnn(|ua]ity  of  the  pupils  may  occur  in 
large  effusions  that  by  pressure  weaken 


CEREBRAL  HEMORRHAGE.    SYMPTOMS. 


39 


the  oculomotor  on  that  side  and  thus 
allow  that  pupil  to  dilate.  It  is  conse- 
quently not  rare  in  cases  involving  the 
frontal  lobe  or  basal  portions  of  the  cere- 
brum. In  pons  troubles  anisocoria  is 
common,  though  both  pupils  may  be 
large  or  small  according  to  the  degree 
of  third-nerve  involvement.  In  menin- 
geal forms  the  pupils  are  often  affected, 
though  there  is  no  rule  here  for  our 
guidance. 

Conjugate  deviation  of  the  eyes  very 
often  points  to  a  lesion  on  the  same  side, 
but  this  is  not  an  invariable  rule. 

Diplopia  or  more  distinct  evidence  of 
paralysis  of  external  ocular  muscles  is 
unusual  except  in  comatose  conditions. 
Its  interpretation  depends  on  the  indi- 
vidual case. 

Ophthalmoscopical  changes  are  not 
sufficiently  marked  in  the  early  stages  to 
be  of  any  value,  nor  are  they  often  much 
more  so  in  the  later.  After  development 
of  the  full  apoplectic  state  there  may  be 
some  choking  of  the  retinal  veins,  espe- 
cially on  the  side  of  the  lesion.  Miliary 
aneurisms  have  been  observed  in  the 
retina,  but  are  quite  unusual.  Ha°mor- 
rhages  of  the  retina  may  indicate  ne- 
phritis; but  only  to  that  extent  suggest 
the  cause  of  any  cerebral  condition. 

Bowels. — Constipation  frequently  pre- 
cedes or  accompanies  the  attack.  Or,  on 
the  contrary,  where  there  is  deep  uncon- 
sciousness or  prolonged  stupor,  and  espe- 
cially if  drastic  purgatives  are  given,  in- 
voluntary discharges  may  occur.  Their 
chief  importance  lies  in  the  necessity, 
then,  of  scrupulous  care  lest  eczema  and 
bed-sores  develop,  and  in  the  commen- 
tary they  offer  on  the  state  of  con- 
sciousness or  the  possibility  of  dementia. 

Urine. — At  the  onset  the  urine  is  usu- 
ally acid.  Transient  glycosuria  is  a  pos- 
sible accompaniment  of  luTmorrhage  in 
any  part  of  the  brain.     The  sugar  usu- 


ally disappears  from  the  urine  in  from  a 
few  hours  to  a  couple  of  days.  Pre- 
sumably it  originates  from  shock  to  the 
so-called  sugar-centre.  When  this  spot 
in  the  floor  of  the  fourth  ventricle  is 
directly  involved,  the  sugar  may  persist 
longer,  though  it  usually  subsides,  even 
then,  in  a  week  or  two. 

As  a  part  of  the  same  manifestation 
there  may  be  a  polyuria  simply,  that  is 
then  even  more  fleeting  in  character. 

Albuminuria  is  a  frequent  and  more 
serious  accompaniment.  Like  the  pre- 
ceding symptoms,  it  may  be  but  tran- 
sient in  character;  but  its  presence  is 
always  a  cause  for  anxiety.  Many  cases 
of  apoplexy  are  due  to  Bright's  disease, 
and  an  examination  of  the  urine,  there- 
fore, should  be  a  routine  procedure  in  all 
cases. 

Hemicliorea. — This  is  of  rare  occur- 
rence. It  may  either  precede  the  attack 
(prehemiplegic  chorea),  though  this  is 
unusual  where  hoBmorrhage  is  the  cause, 
or  it  may  develop  during  the  recovery 
stage  (posthemiplegic).  It  is  thought 
to  be  due  to  irritation  either  of  the  motor 
tracts  or  else  of  some  band  of  fibres 
closely  associated  with  these.  It  is  a 
symptom  of  irritation  rather  than  of  de- 
struction, and  hence  is  never  present 
where  the  paralysis  is  complete.  If  an 
inaugural  symptom,  then  it  disappears 
as  the  paralysis  deepens;  otherwise  it 
comes  on  as  the  paralysis  begins  to 
mend,  and  in  turn  also  disappears  as 
the  paralysis  wears  away.  Hence  its 
appearance  in  convalescence  is  a  good 
omen,  however  annoying  to  the  patient. 
It  is  not  a  symptom  of  the  attack  itself. 

This  affection  involves  strictly  one 
side  of  the  body  only.  It  may  take  in 
principally  an  arm  or  the  lower  extrem- 
ity, but  usually  involves  both  more  or 
less.  In  degree  it  varies  much  according 
to  the  stage;  but  is  often  severe  and  con- 


40 


CEREBRAL  HEMORRHAGE.    SYMPTOMS. 


tinuous  in  character.  The  type  of  move- 
ments is  hardly  different  from  that  of 
ordinary  chorea  of  childhood. 

Tendon-reflexes. — At  the  onset  and 
during  the  period  of  development  no 
great  changes  in  the  reflexes  can  be  made 
out,  unless  diminution.  But  so  soon  as 
the  effusion  seriously  interferes  with  the 
motor  path  and  even  more  after  the  sub- 
sidence of  shock  the  tendon-reflexes  of 
the  paralyzed  parts  show  a  decided  in- 
crease; this  may  apply  both  to  the  force 
of  the  reflex  and  to  the  extent  of  area 
from  which  it  is  elicitable.  In  gross 
lesions  the  pathological  jerks  like  ankle- 
clonus  and  wrist-clonus  may  also  be 
demonstrable,  either  immediately  and 
temporarily,  or  later  on  after  descend- 
ing degeneration.  It  is  necessary  to 
compare  the  two  sides  to  settle  the 
relevancy  of  the  symptom.  Even  then 
there  are  cases  in  which  both  knee-jerks 
are  increased  from  unilateral  lesion,  in 
proportion,  perhaps,  to  an  incomplete 
decussation  of  the  pyramidal  tracts,  as 
is  further  shown  by  the  somewhat  bi- 
lateral paralysis  of  the  lower  extremi- 
ties. As  a  rule,  however,  we  find  a 
purely-unilateral  exaggeration  of  the 
tendon-reflexes. 

OxnEU  Symptoms. — Those  pertaining 
to  the  period  of  the  seizure  are  almost 
described  by  their  enumeration. 

A  slightly-subnormal  temperature 
(one  to  two  degrees)  may  frequently  be 
found  for  an  hour  or  two  after  the  onset. 
Later  an  increase  of  temperature  is  not 
unusual.  It  amounts  to  but  a  few  de- 
grees at  most  and  is  transient  in  char- 
acter, lasting  only  a  few  hours,  as  a  rule. 
These  variations  in  temperature  are 
somewhat  commensurate  with  the  sever- 
ity of  tlie  seizure.  From  the  experi- 
ments of  Ott  and  otliers  it  is  known  that 
there  are  so-called  heat-centres  as  far 
corticad  as  the  caudate  nucleus,  and  it 


is  to  disturbance  of  these  that  the  hyper- 
thermia is  doubtless  due.  It  is  claimed 
for  pons  hffimorrhage  that  the  tempera- 
ture may  rise  from  the  start. 

Trouble  in  swalloM'ing  (dysphagia) 
may  be  simply  an  expression  of  the  gen- 
eral weakness,  though  at  times  it  seems 
to  partake  of  the  nature  of  a  central 
paralysis.  It  necessitates  extra  care  lest 
food  slip  down  the  trachea. 

The  respiration  is  often  affected. 
Stertorous  breathing  is  an  attendant  on 
the  deeply-comatose  state.  In  the  sub- 
sequent weak  condition  of  the  severe 
cases  Cheyne-Stokes  respiration  may  ap- 
pear at  any  time  and  is  especially  prone 
to  do  so  in  the  hours  of  deep  sleep.  It 
may  also  occur  in  the  primary  coma. 

The  subsequent  mental  condition 
often  shows  impairment  of  intelligence, 
psychical  functions,  memory,  and  mental 
grasp.  These  incline  to  be  the  greater, 
the  severer  the  attack.  Laughing  or 
crying  on  inadequate  provocation,  an 
anxious  haste  in  carrying  out  anything 
planned,  and  many  other  aberrations 
might  be  cited. 

PERrPHERAL  TROUBLES.  — •  Contract- 
ures.— These  may  develop  some  weeks 
after  the  attack,  and  are  usually  spastic 
and  functional  rather  than  organic. 
They  are  associated  with  great  increase 
of  the  tendon-reilexes.  By  a  slow, 
steady  counter-pressure  complete  ex- 
tension can  be  effected,  but  the  part 
quickly  becomes  flexed  again  on  relaxa- 
tion. This  condition  means  little  else 
than  that  the  corresponding  fibres  of 
the  pyramidal  tract  are  involved.  Sep- 
arate from  this  is  the  early  rigidity  due 
to  stimulation  of  the  motor  tracts  by  the 
irritative  lesion. 

OSdema. — Tliis  condition  of  the  par- 
alyzed part  is  not  of  very  frequent  oc- 
currence. It  has  been  thought  to  be 
due  to  degeneration  of  the  pyramidal 


CEREBRAL  HjEMOERHAGE.    DIFFERENTIAL  DIAGNOSIS. 


41 


tract,  but  it  sometimes  develops  so  early 
after  the  apoplectic  seizure  that  the 
neural  change  could  hardly  have  taken 
place.  The  amount  of  swelling  may  be 
little  or  much,  and  changes  readily  with 
the  position  of  the  patient.  It  collects 
at  the  most  dependent  part  of  the  ex- 
tremity. 

Neuritis. — Occasionally  a  degenera- 
tive neuritis  develops  in  the  affected 
area.  Considerable  pain  may  be  asso- 
ciated with  it,  though  this  must  not  be 
confused  with  the  muscular  tenderness 
that  often  follows  directly  on  the  paral- 
ysis. The  reason  for  the  occurrence  of 
this  form  of  neuritis  is  not  well  under- 
stood. Possibly  it  is  an  outside  process 
grafted  on  such  nerve-fibres  as  have 
least  resistance. 

Decubitus. — This  is  not,  as  a  rule,  as 
liable  to  occur  or  as  resistant  as  in  dis- 
orders directly  involving  the  peripheral 
neurons.  Still,  from  the  inability  of  the  . 
paralyzed  patient  to  relieve  pressure  on 
prominent  parts,  from  the  maceration  by 
the  discharges  when  not  scrupulously 
cared  for,  and  from  the  frequently  im- 
paired sensation,  it  is  very  easy  for  bed- 
sores to  develop. 

Trophic  changes  are  supposed  to  be 
due  to  trouble  with  the  innervation  from 
the  peripheral  neurons;  but  Nothnagel 
and  others  have  adduced  some  facts  in- 
dicative of  trophic  influence  from  certain 
parts  of  the  brain.  Vasomotor  disturb- 
ances, lowered  arterial  tension,  etc.,  are 
observed  on  the  paralysed  side. 

Differential  Diagnosis. — This  has  to 
be  made  between  liaGinorrhage  and  the 
following  conditions:  Embolism,  throm- 
bosis (including  its  precedent  conditions, 
such  as  syphilitic  arteritis),  pseudoseiz- 
ures,  certain  toxaemias  (as  urremia,  gout, 
alcoholism,  etc.),  simple  fainting,  hys- 
teria, and  sudden  death  from  various 
causes. 


The  practice  of  uniting  nearly  all 
of  these  under  the  one  head  of  apoplexy 
is,  unfortunately,  too  common.  While 
our  diagnostic  methods  are  not  sufficient 
for  all  cases,  the  following  principles  will 
usually  suffice  to  differentiate.  Good 
medical  judgment  is  here  a  strict  neces- 
sity. To  know  our  patients,  their  past 
histories,  and  any  chronic  disorders  from 
which  they  may  be  suffering  is  of  great 
advantage. 

Embolism. — Against  embolism  speak: 
the  absence  of  any  distinct  mitral  or 
aortic  lesion,  the  presence  of  headache 
or  other  prodromal  manifestation;  deep 
coma,  especially  late  development;  vom- 
iting, pronounced  anisocoria,  and  ad- 
vanced age. 

Thrombosis.  —  Against  thrombosis 
speak:  youth  unless  the  patient  be  a 
syphilitic,  coincident  or  early  rise  of 
bodily  temperature,  early  and  deep  coma, 
vomiting,  great  inequality  of  the  pupils, 
high  barometric  pressure  at  time  of 
onset,  beginning  of  attack  when  the  per- 
son is  under  effort  or  excitement,  a  pulse 
of  high  tension,  the  absence  of  prodro- 
mata,  and  the  existence  of  vigorous  gen- 
eral health. 

PsEUDOSEiZDEES. — The  question  of  a 
pseudo-attack  can  only  arise  where  the 
subject  is  also  suffering  from  either  pro- 
gressive dementia,  tabes,  disseminated 
sclerosis,  or  possibly  the  results  of  alco- 
holism. 

The  other  possibilities  can  be  ex- 
cluded more  readily  and  on  general 
lines. 

Following  conclusions  reached  from 
study  of  eight  cases  of  cerebral  htcmor- 
rhage,  embolism,  and  thrombosis:  1.  In 
cases  of  hemiplegia  from  cerebral  hccra- 
orrhage  which  terminate  fatally,  large 
hoemorrhages  arc  not  frequently  found  in 
the  retina  on  the  same  side  as  the  brain- 
lesion,  while  no  hnemorrhages  are  pres- 
ent in  the  opposite  retiLO.    2.  In  cerebral 


42 


CEREBRAL  HAEMORRHAGE.    ETIOLOGY. 


embolism  the  same  retinal  condition  is 
occasionally  met  with;  also  in  cerebral 
embolism  occasionally  the  retinal  vessels 
are  slightly  dilated  on  the  side  of  the 
brain-lesion.  3.  In  thrombosis  of  the 
middle  cerebral  artery,  when  the  throm- 
bosis extends  down  into  the  internal  caro- 
tid, the  vessels  of  the  retina  on  the  side 
of  the  brain-lesion  may  be  markedly  di- 
lated and  tortuous,  while  the  retinal  ves- 
sels of  the  other  eye  are  normal.  R.  T. 
Williamson  (Brit  Med.  Jour.  June  11, 
'98). 

The  term  apoplexy  is  still  loosely 
used  even  by  the  best  writers.  Cerebral 
arterial  disease  is  almost  never  due  to 
vascular  involvement  of  the  brain,  ex- 
cepting when  the  cardiac  or  respiratory 
centers  are  involved.  Sudden  death  is 
almost  always  due  to  heart  disease.  A 
diagnosis  between  cerebral  haemorrhage 
and  thrombosis  is  desirable,  but  impos- 
sible. In  haemorrhage  the  treatment 
should  be  directed  to  lower  vascular 
pressure,  while  in  thrombosis  exactly 
the  opposite  line  of  procedure  should 
be  employed.  H.  N.  Moyer  (Amer. 
Medicine,  May  25,  1901). 

Differential  symptoms  of  pons  haemor- 
rhage as  compared  with  cerebral  haemor- 
rhage: (o)  Headache,  malaise,  vomiting. 
(6)  Sudden  and  profound  coma,  (c) 
Twitching  of  the  face  and  limbs  or  both, 
(d)  Miosis  and  convergent  strabismus 
or  conjugate  deviation  (away  from  the 
side  of  the  lesion),  (e)  Slow,  irregular 
breathing.  (/)  Irregular  pulse,  {g)  Dys- 
phagia, (h)  Paralysis  of  limbs  or  crossed 
paralysis  and  exaggerated  reflexes,  (i) 
Gradual  rise  of  temperature,  sometimes 
to  high  points.  (/)  Death  inside  of 
twenty-four  hours. 

Acute  softening  of  the  pons-medulla  is 
probably  more  frequent  than  haemor- 
rhage. It  may  be  divided  into  three  gen- 
eral groups:  1.  The  syndrome  of  medul- 
lary softening.  2.  The  syndrome  of  pons 
softening.  3.  A  general  syndrome,  in- 
cluding symptoms  seen  in  lesions  of  both 
pons  and  medulla,  or  in  lesions  in  which 
the  focus,  while  lying  in  one  part,  ex- 
tends into  the  other.  This  latter  symp- 
tom group  is  as  follows:  (1)  hemiplegia; 
(2)  pain-temperature;  (3)  ancesthesia 
on  the  same  side  as  hemiplegia;   (4)  loss 


of  deep  (muscular)  sensibility,  with 
ataxia,  often  on  opposite  side  to  hemi- 
plegia; (5)  lateropulsion  to  side  of  le- 
sion; (6)  paralysis  of  various  cranial 
nerves,  especially  seventh  to  twelfth,  on 
the  side  opposite  to  the  hemiplegia;  (7) 
dysphagia  and  dysarthria;  (8)  paralysis 
of  sympathetic  on  same  side  as  lesion, 
with    miosis    and    refraction    of    globe; 

(9)  subjective  sensations  of  vertigo, 
roaring   in   ears,   parathria,    and    pain; 

(10)  disturbances  in  rhythm  of  pulse  and 
respiration.  C.  L.  Dana  (Medical  Rec- 
ord, Sept.  5,  1903). 

Etiology. — The  immediate  cause  of 
the  hsemorrhage  is,  of  course,  the  rupt- 
ure of  some  vessel,  usually  an  artery, 
but  occasionally  a  vein.  Back  of  these 
vascular  changes  we  come  to  the  real 
causes  that  interest  the  practitioner.  And 
here  there  is  a  broad  distinction  between 
senile  conditions  and  those  other  factors 
that  may  be  active  at  any  period  of  life. 
In  the  young  a  considerable  propor- 
tion of  the  rare  cases  is  due  to  the  rupt- 
ure of  some  single  large  aneurism  in  the 
vessels  of  the  pia;  as  to  their  etiology, 
little  is  known.  Except  for  these  and  be- 
fore the  advent  of  senility  we  find  either 
nephritis,  syphilis,  local  softening,  trau- 
matism, abnormal  blood-conditions,  or 
possibly  certain  nervous  influences  as 
the  predominant  causes. 

Miliary  aneurisms  have  much  less  to 
do  with  its  causation  than  has  previ- 
ously been  held,  and,  apart  from  mechan- 
ical causes,  such  as  trauma,  etc.,  haemor- 
rhage of  the  brain  is  most  frequently  due 
to  disease  of  the  vessels  that  causes  a 
loss  of  elasticity  in  their  walls.  Typical 
miliary  aneurisms  are  rare,  but  ather- 
omatous and  syphilitic  changes  of  the 
vascular  walls  play  a  very  extensive  rOle. 
Mechanical  causes  are  more  common 
than  is  commonly  held  to  be  the  case  in 
producing  hicmorrhagc,  without  any 
real  arterial  disease  suHicicnt  of  itself 
to  produce  it.  L.  Stein  (Deut.  Zeit.  f. 
Nervenh.,  vol.  vii,  p.  313,  'OB). 

Case  in  an  infant  5  days  old.  Not- 
withstanding absence  of  marked  cerebral 


CEREBRAL  HAEMORRHAGE.     ETIOLOGY. 


43 


symptoms,  extensive  hoemorrhage  into 
the  brain,  no  convulsions  or  even  un- 
consciousness were  present.  T.  M.  Rotoh 
and  A.  H.  Wentworth  (Boston  Med.  and 
Surg.  Jour.,  Aug.  15,  '95). 

Case  of  mixed  haemorrhage  and  throm 
bosis  secondary  to  mitral  disease  in  a 
child  7  years  old.  Fox  (London  Lancet 
Jan.  27,  '94). 

While  cerebral  hoemorrhages  often  fol 
low  the  development  of  small  aneurisms, 
and  embolic  lodging  in  arteries  may 
cause  the  development  of  aneurisms 
aneurism  with  subsequent  cerebral 
hoemorrhage  as  the  result  of  verrucose 
endocarditis  may  also  occur.  In  3  cases 
— the  patients  being  32,  45,  and  50  years 
of  age,  respectivelj' — fatal  cerebral  htem- 
orrhage  could  be  ascribed  to  the  lodg- 
ment of  a  septic  embolus,  a  fresh  endo- 
carditis ingrafted  on  old  disease  being 
found,  the  arteries  and  the  kidneys  be- 
ing healthy.  Four  other  illustrative 
cases  mentioned.  M.  Simmonds  (Deut. 
med.  Woch.,  May  30,  1901). 

In  traumatic  cases  the  violence  is  a 
sufficient  explanation.  As  a  rule,  the 
hfemorrhage  results  promptly.  But  there 
are  now  several  cases  on  record  showing 
that  several  hours  or  days,  even  a  week 
or  more,  may  intervene.  These  are 
mostly  meningeal  forms,  yet  it  is  cer- 
tain that  some  are  intracerebral.  It  is 
these  cases  of  delayed  apoplexy  that 
serve  to  associate  the  traumatic  with  the 
other  varieties. 

Nephritis  is  one  of  the  most  certain 
causes.  The  arteriosclerosis  that  de- 
velops may  later  degenerate,  allowing 
the  vascular  tunics  to  give  way.  In'any 
case  the  heightened  blood-pressure  and 
perhaps  the  circulating  toxins  so  weaken 
the  arterial  wall  that  under  some  sudden 
stress  it  breaks. 

Syphilitic  alterations  of  the  vascular 
parietes  seem  at  times  to  be  the  imme- 
diate cause  of  their  rupture;  though  this 
claim  needs  a  better  basis  than  the  fact 
that  the  patient  is  a  specific  or  that 
antisyphilitic  remedies  produce  a  good 


effect.  Much  more  certain  are  the  cases 
where  the  break  results  indirectly.  In 
them  a  former  specific  arteritis,  that  may 
long  since  have  run  its  course,  has  left 
behind  it  a  cicatricial  and  hence  weak- 
ened spot  which  ever  after  remains. 
Like  §11  sear-tissue,  this  has  less  resist- 
ance and  too  often  in  time  yields.  This 
point  bas  been  strongly  urged  by  Gow- 
ers.  There  are  also  evidently  other  cases 
in  which  softening  of  this  origin  makes 
the  intermediary  link  to  vascular  rupt- 
ure. In  neither  of  these  latter  forms  can 
specific  treatment  well  have  any  value; 
they  differ  only  etiologically  from  the 
general  run. 

Of  100  non-fatal  personal  cases  36 
were  due  to  syphilis;  they  occurred  in 
early  life  and  were  often  multiple  in 
character.  Cerebral  htemorrhages  were 
rarely  repeated.  Many  cases  showed 
changed  vital  conditions  and  personal 
habits.  C.  L.  Dana  (N.  Y.  Med.  Jour., 
Jan.  5,  '95). 

Local  softening.  This  may  be  due  to 
traumatism,  embolism,  septic  infection, 
syphilis,  or  whatever  other  cause.  The 
focus  is  usually  not  a  large  one,  and  not 
the  cause  of  any  definite  sjTuptoms.  Even 
if  its  presence  were  known,  it  is  hard 
to  see  how  anything  could  be  done  to 
remedy  it  or  ward  off  this  particular 
sequel.  The  prevention  of  the  softening 
must  depend  on  the  general  management 
of  those  affections  that  lead  to  it. 

Abnormal  constitutional  blood-condi- 
tions, such  as  scorbutus,  purpura,  per- 
nicious anjemia,  leucocythaDmia,  and 
severe  infections  with  hai^morrhagic  di- 
athesis may  act  as  efficient  weakeners  of 
the  vessel-parietes.  IlEcmophilia  is  not 
known  as  a  cause,  however  much  it 
might  darken  a  case. 

Nervous  influences.  The  probability 
of  these  as  a  factor  was  suggested  by  the 
writer  to  explain  certain  occasional 
peculiarities,  as  the  onset  during  sleep, 


44 


CEREBRAL  HEMORRHAGE.     PATHOLOGY. 


when  the  blood-pressure  is  lowest,  the 
absence  of  aneurisms  as  a  source  of 
haemorrhage  in  many  cases,  the  asserted 
occurrence  of  prodromata  at  times,  and 
especially  the  occurrence  of  symmetrical 
haemorrhages.  It  is  to  the  vasomotor 
control  of  these  parts  that  such  action 
must  be  assigned.  This  principle  rests 
on  the  close  bilateral  association  of  the 
brain-hemispheres,  and  presumes  that 
any  general  influence — as  from  the 
abdominal  or  thoracic  viscera,  reach- 
ing some  centre  or  part  of  one  hemi- 
sphere— affects  at  the  same  time  or  in 
immediate  sequence  its  opposite  in  like 
manner.  Possibly  by  allowing  a  dilata- 
tion of  the  arteries  to  the  respective  parts 
a  strain  is  exerted  on  the  vessels  sec- 
ondary thereto,  and  thus  weak  points 
give  way.  Whether  this  cause  can  of 
itself  be  sufficient  or  whether  it  at  most 
is  only  an  immediate  cause  cannot  be 
stated. 

Two  cases  of  apoplexy  which  were 
considered  as  hysterical.  Trophic  lesions, 
such  as  oedema  and  hfemorrhage,  as  ob- 
served elsewhere  in  the  body,  may  exist 
in  the  brain,  according  to  his  view.  Hys- 
terical hiEmatemesis,  hjemoptysis,  and 
ecchymosis  are  well  known ;  there  is  no 
reason  why  similar  lesions  should  not  be 
found  within  the  cranial  cavity.  There 
was  no  autopsy  in  either  of  the  cases;  if 
there  had  been,  the  hysterical  nature  of 
a  haemorrhage  could  not  have  been  dem- 
onstrated in  this  way.  Gilles  de  la 
Tourette  (Bull,  et  Mfimoires  de  la  Soc. 
des  H-Op.  de  Paris,  June  4,  '96). 

The  changes  that  old  age  brings  are 
universally  recognized  as  predisposing  to 
apoplexy.  This  has,  in  times  past,  lead 
to  the  assumption  that  cerebral  haemor- 
rhage was  only  a  matter  of  years.  Be- 
cause senility  is  added  to  the  other  fac- 
tors this  trouble  is  more  frequent  in  the 
aged,  though  it  has  been  found  that  in 
the  very  old  cerebral  thrombosis  is  a 
more  frequent  result.     But,  as  the  pre- 


vious causes  are  quite  as  common  in  the 
younger  or  stress  years  of  life,  there  is  no 
immunity  at  any  period. 

Distinct  from  the  above  are  the  im- 
mediate provoking  causes,  of  which 
there  are  many:  straining  at  stool,  lift- 
ing of  heavy  weights;  plethoric  states, 
as  after  excessive  eating;  rage,  fright, 
the  sexual  act  or  other  great  excitement, 
severe  coughing,  meteorological  condi- 
tions (rise  in  barometer,  fall  in  atmos- 
pheric temperature),  etc.,  come  under 
this  head.  These  all  act  by  increasing 
the  blood-pressure.  Presumably  they 
are,  of  themselves,  insufficient  without 
previous  vascular  change. 

Hereditary  influence.  Case  of  a  man 
of  25,  who  had  a  bilateral  cerebral  h£em- 
orrhage,  whose  father  and  one  brother 
died  of  left  hemiplegia  at  58  and  28 
years,  respectively,  and  whose  sister  died 
of  apoplexy  at  25  years.  No  history  of 
syphilis.  Bernard  (BiJl.  de  la  Soc.  Anat., 
No.  26,  '93). 

Case  of  cerebral  haemorrhage  in  a 
woman  of  52,  with  tumors  of  the  parotid 
and  frontal  regions,  who  received  28 
cubic  centimetres  of  chloroform,  the 
anassthesia  lasting  one  hour  and  Ave 
minutes.  Coma  followed  at  once,  last- 
ing eight  hours;  then  she  gradually 
recovered,  showing  left-sided  complete 
paralysis  of  the  arm,  less  complete  of 
the  leg  and  right  side  of  the  face,  with 
complete  insensibility  in  the  left  arm, 
less  marked  on  the  entire  left  side  of 
the  body.  She  slowly  recovered.  Boureau 
(Revue  de  Chirurgie,  July,  1902). 

Pathology. — This  resolves  itself  into 
three  questions:  (1)  as  to  the  vascular 
changes  preceding  or  attending  the  rupt- 
ure, (2)  as  to  the  blood  thrown  out,  and 
(3)  as  to  the  changes  of  nerve-tissue  re- 
sulting therefrom. 

1.  In  the  usual  spontaneous  cases  we 
find  some  alteration  of  the  vessel-wallt 
that  weakens  their  resistance.  Fatty 
and  atheromatous  degeneration  is  com- 
mon in  the  aged,  and  appears  earlier  in 


CEREBRAL  H.-EMORRHAGE.    PATHOLOGY. 


45 


those  who  have  done  heavy  lifting,  over- 
indulgence in  alcoholics,  or  for  any  cause 
developed  premature  senility.  Nephri- 
tis and  the  uric-acid  diathesis  lead  to 
arteriofibrosis,  which  later  breaks  down. 
Specific  arteritis  leaves  an  atrophic  con- 
dition of  the  vascular  wall,  and  this  may, 
in  time,  yield.  Aneurisms  (miliary) 
sometimes  develop,  as  found  by  Bou- 
chard and  Charcot,  doubtless  on  the 
basis  of  some  of  the  conditions  just  men- 
tioned, and  presently  one  or  the  other  of 
these  may  give  way.  Later  studies  have 
shown  that  far  from  all  spontaneous 
cases  are  due  to  the  rupture  of  such 
aneurisms.  We  must  conclude  that 
weakened  spots  sometimes  give  way 
directly;  i.e.,  without  the  intervention 
of  such  dilatation. 

Three  cases  of  multiple  lesions  of  the 
brain.  These  are  very  uncommon,  hav- 
ing been  the  only  ones  found  out  of  a 
total  of  4000  post-mortem  examinations. 
Clinically  they  are  interesting  because 
the  symptoms  during  life  did  not  lead 
to  suspicion  of  the  presence  of  the  ex- 
tensive lesions  found  post-mortem.  In 
the  first  case  there  was  headache,  un- 
consciousness lasting  two  hours,  and 
muscular  twitchings,  but  no  paralysis 
after  a  htemorrhage  consisting  of  more 
than  an  ounce  of  blood.  After  the  sec- 
ond hiemorrhage  there  were  headache, 
spasm,  but  no  motor  paralysis,  hemia- 
nopia,  and  dementia,  and  yet  the  second 
clot  was  larger  than  the  first,  and  it 
was  only  after  the  third  attack,  when 
more  than  five  ounces  of  blood  was  ef- 
fused, that  hemiplegic  symptoms  and 
coma  supervened.  This  case  is  an  ex- 
ample of  the  adaptability  of  the  brain 
to  rapid  increases  of  intracranial  press- 
ure. Freybergcr  (Edinburgh  Med.  Jour., 
Nov.,  1901). 

In  numerous  other  cases  purely  local 
troubles  so  undermine  the  vessel's 
strength  that  it  ruptures.  The  writer 
has  shown  this  for  foci  of  softening; 
these  erode  and  weaken  the  wall  of 
some  vessel  in  the  involved  area;   then, 


of  course,  rupture  easily  results.  Em- 
bolism also,  and  in  like  manner,  some- 
times occasions  an  early  break  at  the 
point  of  plugging.  Then  tumors  not 
rarely  so  weaken  and  drag  on  the  local 
vessels  that  small  and  large  haemor- 
rhages result. 

There  is  no  conclusive  evidence  that 
either  increased  blood-pressure  or  nerv- 
ous influences  are  ever  of  themselves  suf- 
ficient to  rupture  a  brain-artery,  without 
pre-existing  degenerative  changes  in  the 
vessel-wall. 

Though  any  part  of  the  brain  may  be 
the  site,  there  are  certain  favorite  start- 
ing-points. These  correspond  to  the 
territory  of  the  terminal  arteries,  viz.: 
the  pre-  and  post-  perforating  and  the 
branches  from  the  basilar  entering  the 
pons.  Statistics  regarding  site  have  been 
collected  in  this  country  by  Dana. 

Seventy-seven  personal  cases  appar- 
ently confirming  Dana's  views.  Longest 
duration  since  attack  had  been  twenty- 
two  years.  E.  D.  Fisher  (N.  Y.  Jled. 
Jour.,  Jan.  5,  '95). 

Four     cases     of     traumatic     cerebral 
hemorrhage,  in  all  of  which  the  vessel 
ruptured  was  the  middle  meningeal.     In 
one  case,  a  man  aged  75,  operation  re- 
sulted    in     perfect     recovery.       Rasing 
(Hospitalstidende,   No.    3,    '93)  ;    Little- 
wood   {London  Lancet,  Feb.  17,  '94). 
2.  As  to  the  blood  thrown  out.    There 
is  less  resistance  to  the  outflow  in  the 
gray  than  in  the  white  matter.    It  may 
vary  in  quantity  from  minute  capillary 
extravasations   up   to    those   of   several 
ounces.     Some  coagulation   soon   takes 
place  in  the  extra vasated  blood;  but  be- 
fore this  has  occurred  the  blood — if,  e.g., 
it  has  found  a  way  into  the  cavities  or 
meninges — may  have  scattered  ■widely  in 
these  spaces  and  have  even  passed  over 
in  part  to  the  other  side.    Where,  how- 
ever, it  has  not  broken  through,  but 
been  retained  in  one  focus,  it  remains 
long  enough   and  sufficiently  fluid   to 


46 


CEREBRAL  HJEMORRHAGE.    PATHOLOGY. 


work  its  way  into  all  accessible  inter- 
stices. This  is  assisted,  so  long  as  the 
flow  continues,  by  the  pressure  of  the 
blood  in  the  ruptured  vessel.  As  a  con- 
sequence, the  focus  is  always  irregular 
and  ragged  in  shape.  Much  also  de- 
pends on  the  surrounding  structures;  if 
these  are  stratified  tracts  the  blood 
naturally  makes  a  long  pocket;  if,  how- 
ever, these  are  soft  tissues  or  matted 
fibres,  then  a  more  globular  focus  re- 
sults. 

The  free  fluid  and  granular  material 
is  gradually  absorbed,  leaving  the  char- 
acteristic brownish  pigment  and  some- 
times pultaceous  material  that  long  re- 
mains like  a  cyst. 

Experimental  studies  to  determine  the 
age  of  haemorrhagie  extravasations. 
Haemorrhage  artificially  induced  in  rab- 
bits through  a  trephine-opening.  Ani- 
mals lived  from  one  to  seventy-two  days. 
Certain  changes  in  cellular  metamor- 
phosis and  in  chemical  character  found 
to  occur  with  marked  constancy.  Most 
marked  changes  corresponded  with  the 
first,  second,  fifth,  sixth,  eighteenth, 
twentieth,  and  forty-fifth  days.  Hsemo- 
siderin  is  the  chemical  medium  through 
which  the  age  of  the  haemorrhagie  extrav- 
asation may  be  approximated.  Herman 
Durck  (Review  of  Insanity  and  Nerv. 
Dis.,  June,  94). 

3.  Changes  of  nerve-tissue,  caused  or 
provoked  by  the  haemorrhage.  The  pri- 
mary effects  consist  of  tearing  and  com- 
pression of  the  surrounding  substance. 
The  fibres  and  gray  matter  may  be 
forced  apart,  but  often  they  are  ground 
up,  disintegrated,  and  mixed  with  the 
blood,  making  a  pulp  into  which  pro- 
ject abundant  fragments  of  severed 
tracts.  Where  fibres  are  simply  forced 
apart,  there  may  be  scarcely  any  of  this 
chowdering,  the  compression  of  adjacent 
tissues  being  then  all  the  greater.  In 
limited  efFusions  the  compression  is  ex- 
erted ehieflv  on  the  immediate  neigh- 


borhood; but,  where  the  volume  is 
considerable,  it  may  aft'ect  the  whole 
brain,  as  is  shown  by  the  vomiting, 
coma,  etc. 

Nerve-fibres  once  severed  do  not,  so 
far  as  we  know,  ever  reunite;  conse- 
quently loss  of  function  due  to  this  cause 
must  be  permanent.  On  the  other  hand, 
fibres  whose  function  is  disturbed  by 
compression  or  oedema  inay  yet  regain 
their  usefulness,  and  to  this  is  due  the 
degree  of  recovery  that  we  often  see. 
For  on  this  acute  stage  there  follows  one 
of  reaction.  It  is  largely  due  to  the  ac- 
companying infiltration  and  inflamma- 
tory cedema  of  adjacent  parts  that  so 
many  cases  end  fatally  in  from  two  to 
ten  days.  Even  where  life  is  retained 
this  reaction  still  further  Jeopards  neigh- 
boring structures  and  diminishes  the  ex- 
tent of  eventful  recovery. 

There  are  finally  certain  secondary 
changes  of  nerve-tissue  that  may  de- 
velop. These  affect  only  such  nerve- 
fibres  as  have  either  been  directly  sev- 
ered by  the  effusion  or  so  much  involved 
as  to  be  unable  to  recover  even  their 
trophic  function.  Then  the  portions  of 
these  neurons  that  have  been  cut  off 
from  their  respective  cells  undergo  de- 
generation the  same  as  do  severed  fibres 
in  peripheral  nerves.  In  the  case  of  the 
pyramidal  or  spinal  motor  tracts  this 
degeneration  may  extend  do^vn  the  cord 
to  the  anterior  horns;  but  the  terminal, 
or  spinal,  motor  neurons,  being  inde- 
pendent structures,  are  not  generally 
involved  in  this  process.  Of  course, 
fibres  going  to  other  parts  of  the  brain 
will  degenerate  in  like  manner  if  sev- 
ered from  their  parent-cells.  While  in 
the  peripheral  nervous  system  there  may 
be  a  regeneration  of  severed  or  degen- 
erated fibers,  nothing  of  the  kind  is 
known  to  occur  in  the  central  nervous 
system. 


CEREBRAL  HAEMORRHAGE.    PROGNOSIS. 


47 


Prognosis. — This  must  be  based  on  the 
following  factors  and  on  the  accuracy 
with  which  we  can  determine  them. 
There  are,  however,  two  separate  ques- 
tions in  the  matter  of  prognosis:  one 
has  regard  to  the  continuation  of  life 
and  the  other  to  the  extent  of  recovery 
from  the  attack. 

The  age  of  the  patient.  In  childhood 
the  rare  cases  that  do  occur  are  usually 
severe;  but,  if  the  attack  itself  is  out- 
lived, the  natural  recuperative  power  is 
so  great  that  the  person  will  live  on 
indefinitely.  Improvement  may  be  ex- 
pected for  some  years,  but  entire  recov- 
ery is  unusual. 

In  middle  life  the  outcome  depends 
on  the  causal  trouble  and  the  severity  of 
the  apoplectic  attack.  Where  the  motor 
involvement  is  not  great  or  is  due  to 
indirect  pressure,  practically  complete 
restitution  of  all  functions  is  occasion- 
ally observed.  More  often  some  impair- 
ment of  the  involved  area  remains.  If 
the  primary  cause  still  obtains,  this  also 
interferes  with  recovery  and  the  general 
outlook. 

In  senile  conditions  (tortuous  or  cal- 
cified arteries,  dry  and  wrinkled  skin, 
areus  senilis,  etc.)  but  limited  recovery 
is  to  be  expected.  Life  may  be  pro- 
longed, but  most  depends  on  the 
promptness  with  which  the  attack  is 
checked.  The  subsequent  length  of  life 
depends  much  on  the  kindness  and  care 
with  which  the  chronic  invalid  is  sur- 
rounded. 

Nephritis.  Here  we  must  distinguish 
between  unimportant  secondary  or  cas- 
ual albuminuria  and  real  kidney  disease. 
The  latter,  when  present,  limits  recov- 
ery and  determines  the  eventual  dura- 
tion of  life.  Even  with  this  complica- 
tion, however,  if  the  site  and  extent  of 
the  effusion  be  favorable,  the  paralytic 
condition  may  be  fully  recovered  from. 


Syphilis.  The  existence  of  this  sys- 
temic infection  is  principally  of  etio- 
logical importance.  It  may  constitute 
an  indication  for  treatment,  but  other- 
wise has  little  significance. 

Severity  and  nature  of  the  attack. 
This  is  the  great  guide  to  prognosis. 

Coma,  stertor,  vomiting,  prolonged 
semiconsciousness,  extensive  and  com- 
plete paralysis,  etc.,  indicate  a  large 
effusion  with  much  damage  to  the  brain, 
both  in  local  destruction  and  general 
shock.  Consequently  there  is  immediate 
danger  to  life  and  much  less  chance  of 
functional  recovery  when  life  is  pro- 
longed. In  proportion  as  these  features 
are  less  prominent  the  chances  for  pres- 
ervation of  life  and  for  recovery  are 
increased. 

Prolonged  high  temperature,  or  a  rise 
to  104°  or  106°  F.,  makes  a  fatal  prog- 
nosis probable. 

General  convulsions,  as  indicative  of 
ventricular  rupture  (barring  ura2mia), 
are  a  particularly-bad  omen,  death  usu- 
ally resulting  in  from  a  few  hours  to  a 
few  days. 

Location  and  size  of  the  lesion. 
These  two  features  are  complementary. 
For,  though  much  depends  on  the  site, 
still  a  large  outpour  by  its  mere  volume 
may  include  temporarily  all  the  effects 
of  the  smaller,  and  certain  general  effects 
in  addition. 

Pontile  hasmorrhages  are  more  often 
promptly  fatal,  doubtless  from  the  im- 
portance of  the  local  centres  and  passing 
tracts.  The  outpour  is  also  more  rapid 
because  from  relatively  large  vessels  and 
close  to  the  parent-trunk.  On  the  con- 
trarj',  hemorrhages  of  the  pallium  (that 
part  of  the  cerebral  hemisphere  above 
the  central  ganglia)  commonly  become 
vast  in  size  before  inducing  as  serious 
symptoms. 

Inequality  of  the  pupils  developing  as 


48 


CEREBRAL  ILEMORRHAGE.     TREATMENT. 


a  part  of  the  attack,  especially  where  the 
larger  is  on  the  side  of  the  supposed 
haemorrhage,  siiggests  a  large  focus,  and 
hence  points  to  a  more  serious  condition. 
This  is,  however,  by  itself  quite  inde- 
cisire. 

After  the  acute  stage  has  been  tided 
over  the  extent  of  presumable  recovery 
is  the  main  matter  for  prognosis.  Here, 
besides  the  points  already  presented, 
other  manifestations  have  to  be  consid- 
ered. The  state  of  the  tendon-reflexes 
in  the  involved  area  must  be  determined; 
if  there  is  any  increase  compared  with 
the  other  side,  we  can  pretty  safely  con- 
clude that  some  permanent  injury  of 
nerve-tracts  will  remain,  though  a  slight 
local  increase  is  not  incompatible  with 
apparent  functional  recovery.  Any 
marked  increase  of  these  reflexes — as 
ankle-clonus  or  wrist-clonus  or  a  knee- 
jerk  of  ten  inches,  say — means  lasting 
paralysis.  The  occurrence  of  oedema  or 
contractures  in  the  paralyzed  part  signi- 
fies so  grave  a  lesion  of  the  motor  path 
as  to  preclude  hope  of  recovery. 

The  anaesthesias  that  are  so  frequently 
present  in  the  early  or  acute  stage  rarely 
prove  lasting.  The  occasional  develop- 
ment of  chorea  in  the  affected  extremi- 
ties is  in  so  far  a  good  sign  as  it  indi- 
cates returning  conductivity  of  the  mo- 
tor tracts. 

Three    important    prognostic    indica- 
tions:     1.  Renal   disease   the  most   im- 
portant.    2.  Cheyne-Stokes   respiration. 
3.  Hyperpyrexia.     If    one,    two,    or   all 
three  be  present,  patient  will,  in  all  prob- 
ability,  not  recover.     Diabetes,  chronic 
alcoholism,     typhoid     fever,     idiopathic 
anffimia  will  also  exert  fatal  influence. 
A.  G.  Barrs   (Brit.  Med.  Jour.,  May  18, 
■9.-,). 
Treatment. — It  cannot  be  too  strongly 
urged  that  the  first  desideratum  is  a  cor- 
rect  diagnosis.      Upon    this    must   our 
treatment  primarily  depend  to  be  efTi- 
caciouB,  since  the  adections  that  most 


closely  simulate  cerebral  haemorrhage 
demand  directly  opposite  treatment. 

As  the  therapeutic  indications  in  cere- 
bral hemorrhage  vary  considerably  ac- 
cording to  the  stage  of  the  trouble,  they 
can  best  be  considered  under  four 
heads: — 

Prevention. — In  general  the  prophy- 
lactic management  is  indicated  by  the 
etiological  factors.  If  there  are  any  sus- 
picions of  prodromata,  the  patient  must 
be  warned  against  all  lifting  and  strain- 
ing, the  bowels  be  kept  free  (calomel 
or  salines),  any  overtension  of  the  pulse 
be  eased  by  mild  depressants,  and  the 
patient  kept  in  a  wann  atmosphere  well 
protected  from  all  chilling.  Digitalis 
and  cardiac  stimulants  of  every  sort 
should  be  carefully  avoided.  Any  nerv- 
ous overtension  can  advantageously  be 
remedied  with  bromides,  and  their  use 
here  is  regularly  in  order. 

During  the  AttacJc. — Some  cases  are 
promptly  fatal,  meningeal,  and  ventric- 
ular forms  being  usually  of  this  kind. 
Nearly  always,  however,  the  effusion 
progresses  for  some  time.  It  is  here 
that  the  physician  can  be  of  great  serv- 
ice, and  as  there  is  rarely  time  to  call  for 
consultants  it  is  important  that  every 
practitioner  understand  the  methods 
fully. 

The  first  and  main  object  is  to  stop 
further  haemorrhage.  Our  efforts  should 
he  directed  to  a  lowering  of  the  arterial 
pressure,  and  to  a  derivation  of  the  Mood- 
current  to  other  parts;  i.e.,  in  general  to 
a  reduction  of  the  supply  to  the  brain. 
For  this  purpose  a  variety  of  means  are 
available  and  when  promptly  applied  are 
successful. 

Management  of  cerebral  hDemorrhage 
and  its  abortive  treatment:  1.  Do  not 
Rive  stimulants.  Their  use  in  such  cases 
is  most  reprehensible.  The  patient  is 
prostrated,  and  the  lay  mind  naturally 
turns  to  tonics  and  bracers:    about  the 


CEREBRAL  HEMORRHAGE.    TREATMENT. 


49 


worst  thing  that  can  be  done.  2.  Do 
not  resort  to  saline  injections.  During 
the  acute  stage  a  limitation  of  fluids  is 
in  order.  3.  Do  not  use  the  depressant 
diaphoretics,  such  as  ipecac,  pilocarpine, 
or  apomorphine.  They  t«nd  to  nauseate : 
an  inclination  otherwise  too  common, 
and,  in  the  degree  of  attempts  at  vomit- 
ing, most  undesirable.  4.  Do  not  pre- 
scribe digitalis.  It  is  a  dangerous  drug 
in  any  individual  with  a  liability  to 
apoplexy,  and  for  this,  if  for  no  other 
reason,  of  unquestionable  utility  in 
nephritis.  If  anything  of  this  sort  must 
be  used,  strophanthus,  in  the  author's 
experience,  is  by  far  the  safest.  5.  Do 
not  resort  to  opiates.  6.  Do  not  try 
nitrites.  7.  Do  not  permit  any  muscular 
exertion  on  the  patient's  part;  and  mov- 
ing by  others  should  be  limited  as  much 
as  possible. 

In  the  subacute  stage  the  important 
question  is;  when  should  the  patient 
be  encouraged  to  sit  up?  He  should  be 
kept  as  quiet  as  possible  for  the  first 
few  days,  lest  further  effusion  occur 
from  the  same  vascular  rupture.  In 
about  a  week  sitting  up  should  be  en- 
couraged. Give  vascular  depressants  in 
lesser  dose  at  this  time.  Care  should  be 
taken  that  the  patients  should  not  be 
allowed  to  remain  listless  abed  and  thus 
a  secondary  dementia  be  favored. 

In  the  chronic  stage,  which  is  often 
hopeless  enough,  the  use  of  nux  vomica, 
massage,  electricity,  etc.,  is  to  be  tried. 
The  chief  benefit  will  be  derived  from 
cultivating  in  the  patient  whatever 
power  remains.  William  Browning  (New 
York  Med.  Jour.,  Feb.  15,  1902). 

Position  of  the  Patient. — The  main 
essential  is  a  sufficiently  prone  attitude 
to  insure  complete  relaxation  of  all  the 
muscles,  since  we  know  that  muscular 
effort  tends  to  increase  arterial  tension. 
On  the  other  hand,  dropping  the  head 
too  low  favors  the  flow  of  the  blood  to 
the  brain:  a  principle  that  we  apply 
in  cases  of  fainting,  ansmic  exhaustion, 
chloroform  syncope,  etc.  The  best  posi- 
tion, then,  for  a  patient  with  progressing 
cerebral  haemorrhage,  is  to  have  the  body 


sufficiently  reclining  to  be  fully  relaxed 
and  the  head  considerably  elevated. 

When  a  patient  has  sunk  into  a  state 
of  unconsciousness  from  brain  compres- 
sion from  intracranial  hsemorrhage,  a  re- 
covery from  this  state  will  not  occur 
unless  the  compression  is  relieved.  War- 
basse   (Brooklyn  Med.  Jour.,  Jan.,  '99). 

Sometimes  the  vomiting  in  such  a  case 
appears  to  be  eased  by  turning  the  person 
on  the  right  side;  it  is  further  claimed 
that  turning  the  person  on  the  paralyzed 
side  eases  the  stertor. 

Vaso-drugs. — The  proper  use  of  these 
remedies  is  our  most  valuable  single  re- 
source. Ergot  can  well  be  discarded. 
The  cardiovascular  depressants — gelse- 
mium,  veratrium,  or  aconite — are  suffi- 
ciently powerful  and  yet  ordinarily  safe 
means.  Either  of  these  can  be  admin- 
istered hypodermically,  though  they 
also  act  promptly  by  the  mouth.  Where 
the  pulse  warrants  its  use,  it  is  well  to 
begin  with  gelsemium.  In  adults  the 
fluid  extract  can  be  started  with  an 
initial  dose  of  2  to  5  drops  and  fol- 
lowed by  drop-doses  at  intervals  de- 
pendent on  the  closeness  with  which  the 
case  can  be .  watched.  It  should  be 
pushed  until  its  physiological  action  is 
manifest,  whether  little  or  much  is  re- 
quired. The  full  benefit  of  the  drug  is 
not  obtained  unless  its  paralyzing  effect 
is  secured. 

When  medication  on  tliis  line  has  to 
be  continued  for  any  length  of  time,  it 
may  be  necessary  to  change,  especially 
from  full  doses  of  gelsemium.  Then  the 
others  become  useful.  Veratrium  is  next 
in  order;  and  both  because  of  the  more 
general  familiarity  of  the  profession 
with  this  drug,  and  of  our  knowledge  of 
its  safety  from  the  ample  experience 
with  its  use  in  puerperal  eclampsia,  it 
will,  with  most  practitioners,  prove  the 
most  acceptable  remedy  from  the  start. 


2—4 


50 


CEREBRAL  HAEMORRHAGE.    TREATMENT. 


With  the  use  of  aconite  for  this  purpose 
I  have  no  experience;  but,  relying  on  its 
physiological  action,  there  is  no  doubt 
that  in  the  absence  of  either  of  the  other 
drugs  this  might  be  a  fair  substitute. 
It  is  usually  advisable  to  keep  up  some 
influence  of  this  kind  for  from  a  couple 
of  days  to  a  week. 

The  use  of  nitroglycerin  in  this  stage 
of  brain  hemorrhage  almost  certainly 
does  harm,  and  should  be  abandoned. 

All  stimulants,  vascular  tonics,  mor- 
phine, or  opiates,  and,  for  the  time, 
strychnine  should  be  carefully  avoided. 

The  possibility  of  increasing  the  co- 
agulability of  the  blood  by  internal 
agencies  does  not  yet  seem  to  have  been 
realized. 

AutodepMion.  —  This  can  be  prac- 
ticed by  constriction  of  the  extremities 
near  the  trunk.  This  is  a  very  promptly- 
acting,  but  temporary,  expedient  with 
many  limitations.  A  coarse  binder 
should  be  used.  Brittle  vessel-walls  are 
a  distinct  contra-indication.  Only  suf- 
ficient force  should  be  used  to  more  or 
less  shut  off  the  veins  without  affecting 
the  arteries  (if  too  much  we  but  strangle 
the  extremity;  if  too  little  we  fail  of  our 
purpose).  Care  must  be  had  lest  the 
extremity  become  too  cold.  Finally  the 
constriction  must  be  eased  up  gradually, 
lest  the  sudden  influx  into  the  general 
circulation  again  start  up  haemorrhage. 

Warm  bottles  to  the  extremities,  mus- 
tard to  the  soles,  and  gentle  frictions 
are,  of  themselves,  useful  in  drawing 
blood  to  the  parts,  and  are  doubly  so 
when  constriction  is  resorted  to. 

Compression  of  the  carotids  is  a  doubt- 
ful measure,  as  the  vessels  in  older  pa- 
tients are  easily  injured  and  a  steady 
control  of  the  current  for  any  length  of 
time  is  rarely  possible.  Ligature  of  a 
carotid  is  literally  adding  injury  to  in- 
sult. 


Ice  to  the  head  is  a  popular  plan,  but 
also  of  very  uncertain  value.  If  used  at 
all  for  this  purpose,  it  might  far  better 
be  applied  over  the  carotids  in  the  neck. 

Depletion  of  Body-fluids.  —  Formerly 
this  was  the  main  treatment,  and  prac- 
ticed in  the  form  of  venesection.  Many 
still  think  highly  of  this  procedure  for 
vigorous  patients  with  a  tense  pulse. 
"The  indications  for  venesection  are  a 
regular,  strongly-acting  heart,  and  an 
incompressible  pulse." 

The  most  common  and  still  accepted 
method  is  by  purgatives,  as  a  drop  of 
croton-oil  on  the  tongue,  a  good  dose 
of  calomel,  or  a  glycerin-and-sulphate-of- 
soda  enema. 

Pilocarpine  might  be  admirable,  since 
it  acts  both  as  a  depressant  and  a  fiuid- 
depleter,  but  for  certain  risks,  as  of  pul- 
monary cedema. 

There  may  be  other  matters  that  re- 
quire attention.  Convulsions  should  be 
promptly  stopped,  and  for  this  purpose 
a  few  whiffs  of  chloroform  may  suffice. 
The  efforts  of  vomiting  are  injurious, 
but  it  is  seldom  possible  to  arrest  them. 

If  the  bladder  is  full,  catheterization 
may  be  necessary. 

Treatment  of  the  Eeaction  {or  the  Sub- 
acute Stage). — Here  there  is  still  some 
shock,  an  actual  destruction  of  brain- 
tissue,  a  compression  of  adjacent  tracts 
by  the  extravasation,  and  an  inflamma- 
tory reaction  of  immediately-surround- 
ing parts.  We  have  little  to  offset  this. 
Counter-irritation  can  hardly  act  that 
deeply.  Iodides,  to  favor  quick  absorp- 
tion of  clot,  are  the  routine  treatment. 

Trephining,  with  evulsion  of  clots, 
would  be  in  order  in  this  condition, 
although,  owing  to  difficulty  in  exact 
localization  and  the  usual  depth  of  the 
focus  below  the  surface,  such  operative 
relief  is  rarely  feasible.  During  this 
period   we   may  have   to    continue   de- 


CEREBRAL  HEMORRHAGE.    TREATMENT. 


51 


pressants,  and  wait  with  nux  vomica  or 
its  alkaloids.  "Negatively  the  use  of 
digitalis  in  a  patient  who  has  once  suf- 
fered from  brain-haamorrhage  is  ever 
after  a  risky  matter." 

Case  of  traumatic  htemorrhage  into 
the  white  brain-substance  followed  by 
aphasia,  hemiparesis,  and  Jaeksonian 
epilepsy.  Recovery  after  surgical  inter- 
ference. 

Conclusions:  1.  Extravasations  of  blood 
of  traumatic  origin  can  be  removed  from 
the  brain-substance  by  surgical  methods, 
as  well  as  contused  and  destroyed  brain- 
substance,  and  in  the  same  manner 
pathological  and  circumscribed  portions 
of  brain-matter.  2.  It  is  possible  that 
extravasations  of  blood  other  than  those 
of  traumatic  origin  may  be  removed  by 
surgical  interference.  3.  The  brain  does 
not  resent  surgical  procedures  more  than 
any  other  part  of  the  body.  Borsuk  and 
Wizel  (Archiv  f.  klin.  Chir.,  B.  54,  H.  1, 
'97). 

Two  cases  of  cerebral  haemorrhage 
treated  by  trephining  with  a  view  to 
evacuation  of  the  clot.  In  the  first  case 
a  htemorrhagic  cavity  was  exposed  in 
the  right  parietal  lobe,  and  several  clots 
mixed  with  detritis  of  cerebral  sub- 
stance were  removed,  the  operation  re- 
eulting  in  a  rapid  and  complete  cure. 
In  the  second  case  a  clot  could  not  be 
found,  but  the  patient  gained  consider- 
able benefit  from  the  relief  of  intra- 
cranial pressure  due  to  the  exploratory 
trephining.  The  author,  in  discussing 
the  question  of  surgical  intervention  in 
cases  of  cerebral  htemorrhage,  puts  on 
one  side  the  proposal  to  ligate  the  com- 
mon carotid.  The  benefit  to  be  derived 
from  this  operation  he  holds  to  be  il- 
lusory, as  it  cannot  influence  existing 
lesions,  and  that  it  can  do  good  in  pre- 
venting renewed  htemorrliage  has  not 
been  proved.  Moreover,  it  is  undoubtedly 
a  grave  procedure  and  may  by  itself 
cause  death.  In  the  author's  opinion, 
the  surgeon  should  endeavor  to  expose 
by  trephining  the  seat  of  htemorrhage, 
to  suppress  cerebral  compression  by  re- 
moving the  clots,  and  also  to  prevent  or 
overcome  infection  of  the  attacked  por- 
tion of  brain  by  drainage.   The  cranium. 


it  is  suggested,  should  be  trephined  over 
the  fissure  of  Sylvius. 

The  dura  mater,  having  been  exposed 
by  an  orifice  from  3  to  4  centimetres  in 
diameter,  should  be  incised,  and  the 
brain  punctured  by  an  exploratory 
needle  in  the  direction  of  the  internal 
capsule.  If  a  htemorrhagic  focus  be  dis- 
covered, it  should  be  exposed  by  incision 
of  the  cerebral  substance  and  the  cavity 
be  freely  laid  open  and  drained  by  gau2e. 
This  operation  will,  it  is  stated,  often 
remain  simplj-  an  exploratory  one,  and 
in  many  ctises — as,  for  instance,  those  of 
abundant  effusion  and  ventricular  and 
bulbar  haemorrhages — such  treatment, 
the  author  acknowledges,  will  be  quite 
useless.  In  certain  eases,  however,  life 
may  be  saved  by  exposure  of  the  region 
of  haemorrhage,  and  the  mode  of  inter- 
vention proposed  by  the  author  is  held 
to  be  free  from  risk.  Lambotte  (Ann. 
et  Bull,  de  la  Soc.  de  Jl6d.  d'Anvers, 
July-August,  1902). 

For  the  hemiplegic  after  the  condi- 
tion has  settled  down  into  the  chronic 
stage  our  resources  are  sadly  limited. 
Str}-chnine  or  its  congeners  internally, 
sometimes  electricity  locally  to  the  mus- 
cles, and  care  of  the  general  health  com- 
prise all  that  is  rational  in  customary 
procedure. 

Eecently  a  German  writer  has  done 
good  service  by  calling  attention  to  the 
importance,  in  these  cases,  of  doing 
everything  to  bring  activity  again  into 
the  patient's  impaired  nerve-tracts.  He 
shows  that  by  rousing  these  persons,  lift- 
ing them — when  not  too  feeble — into 
a  sitting  position,  getting  them  once 
more  interested  in  life;  further,  by  ex- 
ercising actively  and  semipassively  the 
paretic  muscles,  we  can  save  the  patient 
from  the  further  degeneration  that  so 
often  ensues  and  may  even  effect  great 
gain.  To  the  value  of  this  principle  I 
can  heartily  subscribe.  Ere  beginning 
this  plan,  however,  we  must  wait  until 
the  danger  of  immediate  relapse  is  past, 


52 


CERIUM.    THERAPEailCS. 


— say,  usually  until  the  end  of  the  first 
week  or  ten  days. 

William  Browning, 

Brooklyn. 

CEEEBKO-SPINAI  MENINGITIS. 

See  Meningitis. 

CERIUM.  —  This  is  an  exceedingly 
rare  metal,  found  in  nature  only  in  the 
form  of  a  hydratecl  silicate.  Its  chief 
source  is  a  Swedish  mineral  known  as 
cerite,  though  it  also  occurs  in  brown 
apatite,  and  is  always  found  in  con- 
nection with  lanthanum  and  didymium. 
Unfortunately  the  salts  that  are  em- 
ployed medicinally  are  often  found  dis- 
appointing in  therapeutic  efficacy,  owing 
to  the  presence  of  these  two  latter  min- 
erals. Cerium  is  white,  very  brittle, 
almost  infusible,  and  insoluble  in  water. 
Its  salts  appear  as  white  granular  pow- 
ders that  for  the  most  part  are  only 
slightly  soluble  in  water  and  alcohol, 
and  one,  the  oxalate,  is  wholly  insoluble 
therein;  with  the  exception  of  the 
valerianate,  all  are  practically  odorless 
and  tasteless. 

Preparations  and  Doses.  —  Cerium 
bromide,  5  to  20  grains. 

Cerium  nitrate,  1  to  10  grains. 

Cerium  oxalate,  2  to  15  grains. 

Cerium  valerianate,  1  to  10  grains. 

Physiological  Action.  —  Practically 
nothing  is  known  as  to  the  physiological 
action  of  the  cerium  salts;  not  even 
their  elimination  is  understood.  They 
are,  however,  tonic,  sedative,  and  ant- 
acid, and  the  bromide  and  valerianate 
are  also  to  some  degree  antispasmodic. 

Therapeutics. — The  bromide  salt  is  a 
comparatively  recent  introduction,  but 
it  is  the  least  valuable  of  the  bromides, 
and  as  a  tonic  and  sedative  inferior  to 
other  preparations.    The  nitrate  was  in- 


troduced by  Sir  James  Y.  Simpson  as 
substitute  for  bismuth  salts,  nitrate  of 
silver,  and  hydrocyanic  acid.  "In 
chronic  intestinal  eruption,  a  peculiar 
and  intractable  form  of  disease  for  which 
arsenic  and  silver  nitrate  are  generally 
prescribed,  Simpson  employed  the  salts 
of  cerium  with  marked  advantage" 
(Waring). 

Gastric  Disorders.  —  In  irritable 
dyspepsia  attended  with  gastrodynia, 
pyrosis,  and  chronic  vomiting  there  is 
no  remedy  so  prompt  and  satisfactory  as 
cerium  oxalate  or  valerianate;  both,  too, 
often  afford  ready  relief  in  the  vomiting 
of  pregnancy;  but,  as  before  remarked, 
it  is  desirable  that  the  salt  be  pure. 

In  seasickness  French  authorities 
praise  the  valerianate;  but  here  it  is 
admittedly  greatly  inferior  to  "amyl- 
nitrite  given  by  the  mouth. 

Oxalate  of  cerium  tried  in  seasickness 
in  doses  of  10  to  25  grains  every  two  to 
three  hours.  It  is  superior  to  any  other 
means  personally  tried.  Also  found 
serviceable  in  hundreds  of  cases  of  sick 
headache  and  in  the  morning  sickness  of 
pregnancy,  but  it  must  be  in  doses  of 
at  least  10  grains  to  do  any  good.  W. 
H.  Gardner  (Med.  Record,  June  2,  '88). 
Cerium  given  in  seasickness  in  doses 
of  Vi  ounce  every  two  hours  in  a  num- 
ber of  cases.  Opinion  expressed  that  it 
will  relieve  moro  patients  than  any 
other  remedy  yet  suggested.  M.  C.  Wal- 
dron  (Med.  Record,  June  23,  '88). 

In  diarrhoeal  conditions,  or  any  form 
of  irritation  of  the  intestinal  tract, 
either  the  oxalate  or  valerianate  prove 
far  superior  to  any  of  the  bismuth  salts; 
so  also  in  any  form  of  vomiting  that  is 
reflex  from  intestinal  or  cerebral  irrita- 
tion, spasmodic  in  character. 

Nervous  Disoiiders. — W hooping- 
cough,  too,  is  sometimes  relieved  in  a 
most  striking  way  by  salts  of  cerium. 

In  epilepsy,  chorea,  and  other  con- 
vulsive diseases  in  which  nitrate  of  silver 


CHAULMUGRA-OIL.    PHYSIOLOGICAL  ACTION. 


53 


is  frequently  employed,  cerium  salts 
deserve  trial,  for,  as  Simpson  remarks, 
they  are  certainly  attended  with  the  ad- 
vantages that,  at  the  same  time,  they 
act  as  tonics  and  sedatives.  Their  use 
may  be  persevered  in  without  endanger- 
ing appetite  or  digestion  and  without 
fear  of  discoloring  the  skin. 

In  some  cases  of  migraine  the  cerium 
salts  afford  speedy  relief;  but  it  is  prob- 
able that  here  the  chief  value  of  the 
remedy  lies  in  its  antacid  effect. 

In  the  gastric  crisis  of  locomotor 
ataxia  cerium  oxalate  may  be  employed 
with  decided  success.  The  duration  of 
the  attack  is  lessened,  the  vomiting 
greatly  reduced,  and  the  pain  and  na  jsea 
relieved,  sleep  returns,  and  alimentation 
is,  to  a  certain  extent,  possible.  Ostan- 
koff  (La  M6d.  Mod.,  Aug.,  '96). 

Case  of  a  woman,  40  years  old,  hys- 
terical, who  was  accustomed  to  take 
oxalate  of  cerium,  and  who  finally  de- 
veloped a  cerium  habit.  She  once  took 
Vj  ounce  in  six  hours  and  during  two 
months  ingested  5  ounces.  No  apparent 
effect  was  noticeable,  though  she  de- 
clared it  made  her  "feel  more  comfort- 
able." Craigen  (Med.  Standard,  Sept., 
'9G;  Med.  Age,  Oct.  26,  '9G). 

CESTODES.  See  Parasites,  Intes- 
tinal. 

CHALAZION.     See  Blepharitis. 

CHANCRE.     See  Syphilis. 

CHANCROID.    See  Syphilis. 

CHAPPED  LIPS.    See  Mouth. 

CHAULMUGRA-OIL.— This  is  a  pale- 
brown  or  yellowish-brown  oil  obtained 
by  expression  from  the  seeds  of  the 
Gynocardia  odorata,  which  is  a  native  of 
farther  India,  more  particularly  of  the 
Malay  Peninsula,  and  is  most  abundant 
in  the  forests  between  Sikkim  and  Han- 
goon.  It  is  always  solid  and  unctuous 
in  the  temperate  zone;    has  a  disagree- 


able taste  and  smell;  and  is  a  compound 
of  palmitic,  hypogasic,  cocinic,  and  gyno- 
cardic  acids,  of  which  latter  a  fair  prod- 
uct will  usually  yield  from  10  to  12  per 
cent.  The  oil  generally  found  in  market 
is  rarely  pure;  and  doubtless  its  vari- 
able characteristics  are  responsible  for 
the  fact  it  no  longer  enjoys  in  Europe 
and  America  the  reputation  that  obtains 
thereto  in  India  and  the  Orient. 

Gynocardic  acid  is  the  active  con- 
stituent. It  is  a  yellow,  unctuous  solid 
with  acrid,  burning  taste,  the  odor  of 
the  oil,  and  melts  at  85°  F.  "With  sul- 
phuric acid  it  strikes  a  green  color,  which 
has  been  cited  as  a  test  for  character  and 
purity;  but,  unfortunately,  palmitic  acid 
gives  the  same  precise  reaction. 

Preparations  and  Dose. — Chaulmugra 
liniment. 

Chaulmugra-oil,  5  to  30  minims. 

Chaulmugra  ointment  (1  to  3). 

Gynocardic  acid,  1  to  5  grains. 

Physiological  Action.  —  Chaulmugra- 
oil  (or  chaulmoogra-oil)  and  gynocardic 
acid  alike  appear  to  be  highly  alterative 
and  tonic  in  action.  Both,  in  medium 
doses,  leave  an  unpleasant  taste  in  the 
mouth,  and  likewise  some  irritation  of 
throat  and  pharynx;  later  a  feeling  of 
nausea  supervenes,  with  oppression  in 
the  epigastrium,  followed,  perhaps,  by 
vomiting,  usually  by  slight  purging,  after 
which  all  symptoms  quickly  subside. 
The  gynocardic  acid  is  less  likely  to 
produce  nausea;  hence  is  more  readily 
tolerated.  Under  continued  administra- 
tion nutrition  seems  to  be  improved,  and 
a  gain  in  weight  is  likely  to  be  observed. 

Applied  locally,  both  are  demulcent 
and  lubricant;  but,  like  all  fatty  sub- 
stances, they  act  more  benignly  when 
the  acute  stages  of  inflammation  have 
passed.  This  fact  should  always  be 
borne  in  mind  when  prescribing  as  an 
ointment  or  liniment  or  when  applying 


54 


CHAULITUGKA-OIL. 


CHLORAL. 


pure    in    skin    affections,    to    inflamed 
joints,  etc. 

Therapeutics.  —  The  inhabitants  of 
southeastern  Asia  have  long  employed 
chaulmugra-oil,  both  externally  and  in- 
ternally, in  the  management  of  leprosy, 
skin  diseases  of  a  chronic  scaly  variety, 
in  scrofula,  rheumatism,  etc.  Its  most 
prominent  effects  have  been  observed  in 
the  tubercular  and  anaesthetic  forms  of 
leprosy. 

Case  of  macular  leprosy  in  boy  of  14. 
Patient  first  manifested  signs  of  the  dis- 
ease at  the  age  of  10,  when  erythematous 
and  pigmented  raised  patches,  mostly 
ansesthetic,  appeared  on  various  parts  of 
the  body.  Chaulmugra-oil  was  given 
in  doses  of  12  drops  daily  with  persistent 
increase,  so  that  by  the  end  of  a  year 
the  daily  quantity  had  become  400 
minims.  The  anaesthesia,  swelling,  and 
erythema  entirely  disappeared  from  the 
patches,  and  the  pigmentation  was 
rapidly  fading.  T.  D.  Savill  (Lancet,  1, 
p.  1283,  1900). 

In  psoriasis,  lupus,  and  allied  skin 
affections;  in  old  eczemas  with  thick- 
ening of  the  skin;  in  scabies  and  ring- 
worm; in  the  form  of  liniment  as  an 
application  in  rheumatic  arthritis,  rheu- 
matic gout,  stiff  joints,  and  strains. 
Mixed  with  chloroform  and  menthol  it 
appears  to  have  been  very  beneficial  in 
some  cases  of  neuralgia,  sciatica,  etc. 

In  giving  the  oil  internally  it  is  best 
to  begin  with  3  or  4  grains,  administer- 
ing after  meals,  and  gradually  increasing 
to  the  limits  of  toleration,  which  will 
usually  be  found  somewhere  between  30 
and  60  grains.  If  the  acid  is  employed, 
it  is  best  administered  in  the  same  way, 
viz.:  */2  grain  after  meals  and  gradu- 
ally increased  to  3  or  5  grains.  It  must 
be  admitted,  however,  that  these  prep- 
arations do  not  seem  as  active  in  the 
temperate  zone  as  in  the  tropics,  and 
that  the  white  races  are  not  so  appre- 
ciably affected  thereby  as  the  dark. 


CHEST,  INJURIES  OF.  See  Wounds 
AND  Injuries  of  Thoeax. 

CHICKEN-POX.    See  Varicella. 

CHILBLAIN.    See  Pernio. 

CHILLS  AND  FEVER.  See  Malarial 

Fevers. 

CHLORAL:  ITS  DERIVATIVES  AND 
COMPOUNDS.— Chloral,  or  anhydrous 
chloral,  is  by  no  means  chloral-hydrate, 
as  is  generally  imagined  and  so  very 
erroneously  taught.  Chloral,  per  se,  is 
a  trichloracetic  aldehyde,  and  can  be 
obtained  only  in  the  form  of  a  color- 
less liquid,  which,  when  shaken  with 
water,  absorbs  one  molecule  of  the  latter 
and  forms  a  solid,  constituting  chloral- 
hydrate.  It  also  possesses  an  aldehyde 
odor;  it  boils  at  201.2°  F.,  while  chloral- 
hydrate  only  boils  at  207°  F.  By  ox- 
idation it  forms  trichloracetic  acid,  and 
the  action  of  nascent  hydrogen  reduces 
it  to  aldehyde;  by  the  alkalies  it  is  at 
once  decomposed  into  chloroform  and  a 
formate  of  the  alkali  employed.  True 
chloral  is  difficult  to  keep,  and  always 
requires  to  be  tightly  corked  in  a  dark- 
hued  container  and  carefully  set  away 
in  a  dark,  cool  place.  It  possesses  little 
interest  for  the  physician,  except  as  be- 
ing a  source  of  chloral-hydrate,  and  the 
fact  that  sulphuric  acid  added  to  the 
latter  causes  it  to  decompose  into  meta- 
chloral  and  chloral. 

Preparations  and  Doses. — Chloralamid 
(chloralamide;  chloral-formamide),  10 
to  45  grains. 

Chloral-ammonium,  15  to  30  grains. 

Chloral-antipyrine  (hypnal),  15  to  30 
grains. 

Chloral-caffeine,  3  to  10  grains. 

Chloral-camphor  (camphorated  chlo- 
ral), topical  chiefly;  internally,  10  to  SO 


CHLORAL.    PREPARATIONS  AND  DOSES. 


55 


Chloral,  croton-  (see  Butyl-chloral). 

Chloral-formamide  (see  Chloral- 
amid). 

Chloral-hydrate,  10  to  50  grains. 

Chloral-imide  (chloralamid;  trichlo- 
rethylidenimide),  10  to  30  grains. 

Chloral-menthol  (menthol-chloral; 
mentholated  chloral),  for  topical  use. 

Chloral-ose,  or  chloralose,  1  to  3 
grains. 

Chloral-quinine,  3  to  10  minims. 

Chloral-thymol,  topical  application 
only. 

Chloral-iirethane  (iiral;  iiraline;  ura- 
lium;  urethane-chloral),  10  to  45  grains. 

Chloral  suppository,  15  grains  of  mixt- 
ure. 

Chloral  syrup,  30  to  120  minims. 

Chlorobrom,  or  chloro-brom:  a  mixt- 
ure of  potassium  bromide  and  chloral- 
amid. 

Bromochloral,  compound  liquid  of,  30 
to  120  minims. 

Butyl-chloral-hydrate,  15  to  30  grains. 

Butyl-chloral  mixture,  4  to  8  drachms. 

Butyl-chloral  pills,  1  every  one  or  two 
hours. 

Butyl-chloral  pills  with  gelsemium,  1 
every  one  or  two  hours. 

Chloral-ammonium  is  a  white,  crys- 
talline powder  with  a  chloral  odor  and 
taste,  soluble  in  alcohol  and  ether,  in- 
soluble in  cold  and  decomposed  by  hot 
water,  melting  at  about  147°  F.  It  is 
employed  as  an  hypnotic  and  analgesic, 
is  claimed  never  to  disturb  the  stomach, 
and  to  be  devoid  of  all  the  unpleasant 
factors  peculiar  to  chloral-hydrate: 
claims  by  no  means  substantiated.  It  is 
employed  chiefly  in  nervous  insomnia 
of  all  kinds  and  also  in  mental  troubles. 

Chloral-antipi/riiie  is,  perhaps,  better 
known  by  its  trade  name:  "hypnal." 
It  is  scarcely  so  much  a  chemical  as  a 
mechanical  compound,  and  is  had  in 
colorless  crystals  that  are  soluble  in  six 


parts  of  water.  It  is  hypnotic,  analgesic, 
antipyretic,  and  antiseptic,  and  chiefly 
employed  in  insomnia,  headache,  spasm, 
cough,  etc. 

Chloral-hydrate  is  the  drug  in  most 
frequent  use,  and,  as  already  remarked, 
is  obtained  by  the  addition  of  one  mole- 
cule of  water  to  anhydrous  chloral, 
whereby  are  formed  crystals  (monoclinic 
prisms)  melting  at  135°  F.,  and  at  207.5° 
separating  into  chloral  and  water;  the 
vapor  is  not  combustible.  It  has  a  some- 
what pleasant,  penetrating,  pungent, 
aromatic  odor,  in  which,  also,  is  speedily 
recognized  more  than  a  mere  suggestion 
of  acridity.  Bitter  to  taste,  it  is  also, 
in  some  degree,  caustic;  is  more  or  less 
volatile  according  to  the  atmospheric 
conditions  to  which  it  is  exposed;  solu- 
ble in  almost  anything  and  everything, 
including  fixed  and  volatile  oils;  and, 
when  triturated  with  equal  proportions 
of  stereopteus  or  camphoraceous  bodies, 
combines  to  produce  a  liquid.  A  great 
deal  of  the  chloral-hydrate  marketed  is 
of  impure  quality,  being  in  combination 
with  chloral-alcoholate  (to  the  presence 
of  which  untoward  accidents  are  fre- 
quently laid),  hydrochlcric  acid,  chlo- 
rides, etc.  The  test  authorized  by  the 
British  Pharmacopoeia  is  that  of  sul- 
phuric acid  acting  on  a  strong  solution 
of  the  drug  in  chloroform,  whereby,  if 
absolutely  pure,  no  brown  color  is  devel- 
oped; the  U.  S.  P.  directs  the  acid  to 
be  employed  withoiit  chloroform  and 
the  mixture  also  to  be  warmed,  and  re- 
quires it  shall  not  blacken.  JIanifestly 
the  last  test  is  not  as  reliable  or  delicate 
as  that  of  the  B.  P.  A  fair  idea  of  purity 
can  be  had,  however,  by  pressing  be- 
tween two  leaves  of  blotting-paper,  when, 
if  impure,  oily  spots  will  be  formed.  It 
should  make  a  neutral  solution  with 
water  without  forming  oily  drops; 
should  not  be  decomposed  readily  by  the 


56 


CHLORAL.     PREPARATIONS  AND  DOSES. 


action  of  the  atmosphere;  the  aqueous 
solution  acidulated  with  nitric  acid 
affords  no  evidence  of  chlorine  when 
treated  with  silver  nitrate. 

Chloral-caffeine  appears  as  colorless, 
glittering,  small  rods  or  leaflets,  solu- 
ble in  water.  It  is  said  to  be  a  molec- 
ular combination  of  the  drugs  repre- 
sented, but  this  has  never  been  defi- 
nitely proved;  certain  it  is  that  alkalies 
decompose  it  into  chloroform  and  caf- 
feine. Being  hypnotic,  sedative,  and 
analgesic,  it  has  been  employed,  both  by 
the  mouth  and  hypodermically,  and  in 
nervous  insomnia,  neuralgia,  sciatica, 
rheumatism,  headache,  etc. 

Chloral-camphor  or  camphorated  chlo- 
ral, thymolated  chloral,  carbolated  chlo- 
ral, quinine-chloral,  and  mentholated  chlo- 
ral, with  the  exception  of  the  first 
named,  are  employed  only  in  a  topical 
way;  all  are  made  by  melting  the  re- 
spective constituents  with  chloral.  Thus 
the  camphorated — which  appears  as  a 
transparent,  almost  colorless,  syrupy 
liquid — is  prepared  by  triturating  equal 
parts  of  gum  camphor  and  chloral-hy- 
drate in  a  warm  mortar;  it  is  soluble  in 
all  proportions  in  alcohol,  ether,  oils, 
and  fats,  but  not  at  all  in  pure  water; 
is  antiseptic,  analgesic,  and  slightly  epi- 
spastic  applied  externally,  and  internally 
administered  powerfully  hypnotic  and 
narcotic. 

Chloral-phenol  is  an  oily  liquid  com- 
posed of  3  parts  of  carbolic  acid  and 
1  part  of  chloral-hydrate;  is  analgesic 
and  antiseptic,  and  employed  by  inhala- 
tion, or  is  topically  applied. 

Chloral-quinine  is  another  fluid  devel- 
oped by  mechanical  mixture  of  two 
drugs,  but  is  more  of  a  curiosity  than  a 
medicament. 

Chloral-menthol  and  chloral-thymol  dif- 
fer little  from  chloral-camphor,  and  are 
put  to  much  the  same  uses. 


Chloral-formamide,  or  chloralamid,  is 
unfortunate  in  having  a  rival  called 
chloralimide  or  chloral-imide,  the  latter 
being  a  trichlorethylidenimide.  Thera- 
peutically, they  are  practically  identical, 
save  that  the  latter  is  about  one-third 
more  active  and  is  not  decomposed  by 
water.  Both  are  obtained  as  bitter, 
lustrous,  colorless  crystals,  decomposed 
by  heat,  soluble  in  alcohol,  1  to  2,  and 
in  water  about  1  to  20.  They  are  hyp- 
notic, but  not  analgesic.  The  claim  is 
advanced  that  vmdesirable  effects  are  less 
frequent  and  less  marked  than  from 
chloral-hydrate,  but  this  is  probably 
true  only  as  regards  the  measure  of 
activity.  Neither  are,  in  any  degree,  uni- 
form as  to  action. 

Chloralose  is  obtained  from  anhydrous 
chloral  and  glucose  by  means  of  heat, 
whereby  are  formed  small,  colorless 
crystals  of  bitter,  disagreeable  taste, 
slowly  soluble  in  water,  readily  so  in 
alcohol.  It  is  deemed  an  hypnotic,  and 
claimed  to  act  by  reducing  the  excit- 
ability of  the  gray  matter  of  the  brain, 
and  also  that  it  is  free  from  the  disa- 
greeable after-effects  manifested  by  the 
heart,  and  the  cumulative  tendency  that 
sometimes  follow  the  exhibition  of  chlo- 
ral-hydrate. Properly  this  compound  is 
an  anhydroglucochloral,  and  in  large 
doses  is  intensely  toxic. 

Chloral-urethane  (known  also  as  chlo- 
ral-carbamide, urethane-chloral,  ural, 
uralium,  and  uraline)  is  obtained  by 
heating  chloral-hydrate  with  urethane, 
then  successively  adding  concentrated 
hydrochloric  and  sulphuric  acids.  It 
appears  both  as  colorless,  shining,  lam- 
inated crystals  and  as  a  white  powder, 
soluble  in  alcoliol  and  ether.  It  is  rec- 
ommended as  an  hypnotic,  especially 
in  epileptic  dementia,  but  is  uncertain 
in  effects  and  disagreeable  to  take,  and 


CHLORAL.    PREPARATIONS  AND  DOSES. 


57 


not  infrequently  nausea  and  disorders  of 
digestion  follow  its  exhibition. 

Chloral-hydrocyanate  conies  in  white 
rhombic  prisms,  or  as  a  white  crystal 
powder,  soluble  in  alcohol,  ether,  and 
water.  It  contains  15.33  per  cent,  of 
hydrocyanic  acid,  and  is  superior  to  the 
latter  in  that  it  is  more  permanent,  and 
the  dose  more  exact.  One  part  dissolved 
in  one  hundred  and  sixty-six  parts  of 
water  makes  bitter-almond  water. 

The  "liquor  iromo-chloral  compositus" 
of  the  British  Pharmacopoeia  is  made  by 
dissolving  1600  grains  of  chloral-hydrate 
in  400  minims  each  of  tincture  of  can- 
nabis Indica,  and  tincture  of  fresh 
orange-peel,  1600  minims  of  henbane- 
juice,  30  drachms  of  syrup,  and  4 
drachms  of  fluid  extract  of  licorice;  then 
is  added  1600  grains  of  bromide  of  potas- 
sium, previously  dissolved  in  7  ounces 
of  distilled  water,  and  the  whole  filtered; 
finally  sufficient  distilled  water  is  added 
to  bring  the  amount  up  to  20  imperial 
ounces. 

Chloral  suppositories,  each  containing 
5  grains  of  chloral-hydrate  and  10  grains 
of  cacao-butter  (oleum  theobroma3),  can- 
not be  made  with  heat,  for  even  if  it 
should  not  wholly  decompose  the  chlo- 
ral, the  mixture  will  not  set  firm;  in- 
stead, the  combination,  which,  by  the 
way,  is  apt  to  be  very  irritating,  must 
be  obtained  by  compression  in  molds. 
The  suppositories  are  very  useful  in  in- 
fantile convulsions  where  nothing  can  be 
administered  by  the  mouth,  and  each 
one  should  be  forcibly  retained  within 
the  sphincter  for  a  few  moments,  by  the 
finger  if  necessary. 

Syrup  of  chloral  is  obtained  by  dis- 
solving 80  grains  of  chloral-hydrate  in 
90  minims  of  water,  and  then  adding 
simple  syrup  enough  to  make  1  ounce. 

Bvtyl-chloral-hydrate — or  croton-chlo- 
ral-hydrate  as  it  is  sometimes,  but  wrong- 


fully, termed — appears  in  pearly-white 
crystalline  scales  possessed  of  a  pungent 
odor  resembling  that  of  chloral-hydrate, 
and  an  acrid  nauseous  taste;  it  is  solu- 
ble, 1  to  43,  in  cold  water,  freely  solu- 
ble in  rectified  spirit,  and  4  to  1  of  glyc- 
erin. It  is  available  in  the  same  way  as 
chloral-hydrate,  and  is  claimed  to  be 
more  efficacious  as  an  analgesic,  espe- 
cially in  neuralgias. 

Buiyl-cMoral-aniipyrine  or  butyl-hyp- 
nal,  appears  as  colorless,  transparent 
needles  of  butyl-chloral  odor  and  bitter 
taste,  which  are  soluble  in  alcohol,  ether, 
chloroform,  benzin,  and  (1  to  30)  water. 
Perchloride  of  iron  gives  a  red  solution; 
alkalies  decompose  into  antipyrine,  alka- 
line formate,  and  propyl-chloroform.  Its 
properties  resemble  those  of  hypnal. 
Butyl-chloral  mixture,  which  is  a  very 
useful  anodyne,  is  made  by  dissolving 
4  grains  of  butyl-chloral  in  15  minims  of 
glycerin  and  water  to  make  1  ounce. 

Butyl-chloral  pills  are  made  of  a 
strength  of  3  grains  each  of  the  drug 
added  to  sufficient  glycerin  of  traga- 
canth  or  mucilage  of  gum  arable  to 
make  a  mass;  when  the  same  are  desired 
with  gelsemium,  hydrochlorate  of  gelse- 
mine,  in  the  proportions  of  V200  of  ^ 
grain,  is  added  to  each  pill. 

Butyl-chloral  syrup  is  merely  16  grains 
of  the  drug  dissolved  in  1  ounce  of  hot 
syrup. 

Glycerile  of  chloral  is  merely  1  part  of 
chloral-hydrate  in  4  parts  of  glycerin, 
and  is  employed  chiefly  as  a  solvent  for 
certain  alkaloids. 

Glycerole  of  camphor  and  chloral, 
which  is  a  very  effective  anodyne  em- 
brocation, is  made  as  follows: — 

^  Camphor,  powdered,  75  grains. 
Chloral-hydrate,  60  grains. 
Glycerin,  4  drachms. 
Alcohol,  3  drachms. 
Juniper-oil,  30  minims. 


58 


CHLORAIi  PREPARATIONS.    PHYSIOLOGICAL  ACTION. 


Mix  in  a  glass  container  and  expose 
to  gentle  heat  (not  over  10-1°  F.)  until 
solution  is  effected.  Let  cool,  bottle,  and 
keep  well  stoppered. 

Carmine-chloral — which  is  so  useful  to 
microscopists  as  a  stain,  and  invaluable 
in  examining  pollen  nuclei — is  made  as 
follows:  Carmine,  2;  absolute  alcohol, 
20;  hydrochloric  acid,  2  parts;  heated 
on  a  water-bath  for  thirty  minutes;  then, 
adding  25  parts  of  chloral-hydrate,  cool 
and  filter. 

Hypodermic  Use. — Chloral-hydrate  has 
been  administered  hypodermically,  but 
is  generally  to  be  condemned  on  account 
of  its  caustic  action,  the  necessity  of 
multiplying  punctures,  and  of  employing 
very  dilute  solutions.  Vulpian  declares 
that  it  tends  to  induce  hsematuria, 
though  not  to  the  same  degree  as  when 
employed  by  intravenous  injection. 
Croton-chloral  is  a  trifle  more  suitable 
from  a  remedial  stand-point,  but  not 
from  a  physical  one;  it  is  also  highly 
irritant.  Leoni  recommends  the  follow- 
ing solution,  16  minims  of  which  con- 
tain '/i  grain  of  the  drug:  Croton- 
chloral,  16  grains;  warm  glycerin  and 
cherry-laurel  water,  of  each,  equal  parts 
up  to  352  minims. 

Physiological  Action. — Externally  ap- 
plied, all  cliloral  preparations  are  more 
or  less  irritant,  but  likewise  antiseptic 
and  sometimes  analgesic. 

Internally  they  are  generally  sedative 
to  the  nervous  system,  and  secondarily 
to  the  heart:  a  feeling  of  lassitude,  of 
irresistible  drowsiness,  or  even  sleep  may 
be  produced  (though  sometimes  preceded 
by  a  stage  of  excitement,  particularly  in 
alcoholics),  slowing  of  pulse  and  respira- 
tion, and  pupillary  contraction.  Sensi- 
bility and  reflex  excitability  are  not  dis- 
turbed by  ordinary  medicinal  doses,  but 
disappear  when  large  amounts  of  the 
drug  are  exhibited.    There  is  also  lower- 


ing of  temperature.  Probably  brain- 
ansemia  is  induced,  whereby  sleep  fol- 
lows, the  act  being  more  nearly  normal, 
physiologicallj',  than  that  produced  by 
any  other  drug,  there  being  no  malaise 
on  awakening. 

Liebreieh,  who  first  introduced  chloral, 
believed  that  it  exerted  its  effect  through 
the  circulation  by  liberating  therein  free 
chloroform  and  formic  acid;  but  this 
seems  improbable,  because  the  alkali  of 
the  blood  is  too  feeble  to  effect  the  trans- 
formation, and  its  albumin  is  considered 
antagonistic  to  such  a  process.  Again, 
no  smell  of  chloroform  can  be  observed 
in  the  breath,  and  no  anaesthetic  effect 
is  produced  on  the  sleeper  by  moderate 
doses.  Farquharson  ("Therap.  and  Mat. 
Med.,"  '89). 

Chloral  has  antiseptic  properties,  de- 
stroying low  organisms  and  preventing 
the  decomposition  they  induce.  Small 
doses  are  without  obvious  effect  upon 
the  stomach;  large  doses  may  be  fol- 
lowed by  nausea  and  vomiting.  Biddle 
("Mat.  Med.  and  Therap.,"  '96). 

Chloral-hydrate  acts  upon  the  cere- 
brum as  a  powerful  and  certain  hyp- 
notic; acts  as  a  depressant  to  the  centres 
at  the  base  of  the  brain;  depresses  the 
functions  of  the  spinal  cord;  produces 
slowness  and  weakness  of  the  heart's 
action,  vasomotor  paralysis,  and  muscu- 
lar weakness  with  anajsthesia.  Murrell, 
Lond.  {"Man.  of  Mat.  Med.  and  Therap.," 
'96). 

Resemblance  of  the  psychosis  of  chronic 
chloral  poisoning  to  natural  sleep  em- 
phasized. The  reason  of  this  will  be 
found  in  the  fact  that,  like  natural  sleep, 
chloralism  is  the  result  of  a  congestion 
of  the  brain  or  of  the  action  of  a  poison 
upon  the  brain-cclls.  A.  F.  Akopenko 
(Vratch,  Apr.  29,  1900). 

Various  drugs  have  been  employed, 
gome  of  them  dangerous,  to  render  people 
8tu])id  and  unconscious  as  an  accessory 
to  robbery.  The  criminal  classes,  how- 
ever, have  largely  settled  down  to  the 
use  of  chloral-hydrate,  and  it  is  from 
30  to  00  grains  of  this  substance,  usually 
administered  with  beer,  that  furnishes 
the  famous  "knock-out"  drops.    Editorial 


CHLORAL  PREPARATIONS.  CHLORALAinD.  CHLORALOSE. 


59 


(Boston  Med.  and  Surg.  Jour.,  Oct.  5, 
'99). 
Butyl-cliloral-hydraie  acts  very  much 
like  chloral-hydrate,  but  is  less  powerful 
as  an  hypnotic,  induces  somewhat  less 
cardiac  depression,  is  not  so  irritating 
to  mucous  membranes,  and  appears  to 
have  a  specific  action  upon  the  branches 
of  the  fifth  pair  of  nerves.  Liebreich 
believes  that  its  action  upon  the  heart 
in  even  fairly  large  doses  is  not  danger- 
ous, and  that  life  can  be  saved  by  means 
of  artificial  respiration  after  the  respira- 
tion-muscles have  ceased  action,  but  the 
erroneousness  of  these  conclusions  has 
been  demonstrated  in  the  physiological 
laboratory.  It  is  evident  that  its  admin- 
istration cannot  be  conducted  with  much 
less  caution  than  that  of  chloral-hydrate. 
It  is  largely  eliminated  by  the  kidneys 
as  vtrobutylchloralic  acid. 

Butyl-chloral-hydrate  has  hypnotic 
powers,  but  it  is  so  rarely  used  for  this 
purpose  that  on  practical  grounds  it 
should  be  dissociated  from  the  group  of 
hypnotics  in  spite  of  many  structural 
and  other  affinities.  It  produces  anaes- 
thesia of  the  head  without  loss  of  sensi- 
bility to  the  rest  of  the  body,  which  in 
man  is  confined  to  the  area  of  the  fifth 
nerve.  In  large  doses  it  produces  sleep, 
and  in  fatal  doses  destroys  by  paralyz- 
ing the  medulla  oblongata.  Ringer  and 
Sainsbury    ("Manual   of  Therap.,"   '97). 

Cliloralamid. — A  marked  effect  of  this 
drug  is  its  tendency  to  produce  mucous 
diarrhoea.  It  acts  more  powerfully  upon 
the  cerebral  cortex  than  any  other  por- 
tion of  the  nervous  system,  causing  sleep 
and  muscular  relaxation;  is  claimed  to 
be  only  feebly  depressant  to  the  cord, 
and  in  medicinal  doses  to  have  little 
effect  upon  the  circulation.  It  was  in- 
troduced as  a  substitute  for  chloral-hy- 
drate, backed  by  the  assertions  that  it 
was  less  unpleasant  to  take,  absolutely 
without  objectionable  effect  on  the  heart, 
and  that  its  hypnotic  effect  is  two-thirds 


that  of  chloral.  Although  it  acts  with 
tolerable  certainty  in  simple  insomnia, 
it  generally  fails,  if  administered  in 
medicinal  doses,  when  pain  and  excite- 
ment are  present.  On  the  whole,  it  can- 
not be  said  to  have  met  the  expectations 
raised  in  its  behalf.  In  moderate  doses  it 
seems  to  sometimes  stimulate  respira- 
tion, rendering  it  deeper  and  fuller,  but 
unless  its  administration  is  carefully 
watched  an  opposite  effect  is  soon  pro- 
duced. 

The  physiological  action  of  chloralamid 
is  similar  to  that  of  chloral  upon  the 
cerebrum,  but  upon  the  circulation  is 
ordinarily  so  slight  as  to  offer  a  marked 
contrast  to  the  depression  produced  by 
the  latter  drug;  only  in  large  or  poison- 
ous doses  does  it  depress  the  heart  and 
cause  a  fall  in  blood-pressure.  A  moder- 
ate degree  of  respiratory  depression  may 
follow  the  administration  of  large 
amounts,  and  death  results  from  paral- 
ysis of  respiration.  It  has  been  thought 
to  have  a  soothing  effect  upon  the  spinal 
centres  and  thus  to  diminish  reflex  ex- 
citability, but  its  action  upon  the  nerv- 
ous system  other  than  the  cerebrum  is 
hardly  appreciable.  It  is  excreted  as 
urochloralic  acid.  Griffin  (Foster's 'Trac. 
Therap.,"  '9G). 

Upon  the  action  of  this  drug  a  large 
amount  of  experience  has  been  accumu- 
lated by  a  number  of  observers,  the  world 
over,  and  the  general  verdict  is  that  it 
does  not  depress  the  heart  or  circulation, 
does  not  lowerteraperature,that  it  exerts 
a  decided  action  in  many  cases  of  in- 
somnia from  pain,  and  that  after-effects 
and  by-effects  are  rarely  witnessed.  At 
the  same  time  it  must  be  admitted  that 
collapse  symptoms  have  been  observed 
in  a  few  cases  and  likewise  erythematous 
eruptions.  It  certainly  is  a  very  valu- 
able hypnotic.  Ringer  and  Sainsbury 
("Handbook  of  Therap.,"  '97). 

Chloralose. — This  drug  was  introduced 
as  a  substitute  for  chloral-hydrate,  with 
the  claim  that  it  is  hypnotic, — causing 
sleep  in  birds  and  mammals  as  well  as 
in    man, — analgesic,    exerts    its    effect 


60 


CHLORAL  PREPARATIONS.  CHLORALOSE. 


chiefly  upon  the  gray  matter  of  the 
brain,  and  unlike  chloral  does  not  de- 
press the  spinal  cord;  also  that  it  is  with- 
out any  irritant  effect  on  either  stom- 
ach or  intestines;  indeed,  that  it  is 
entirely  devoid  of  unpleasant  after-ef- 
fects— all  of  which  has  by  no  means  been 
definitely  substantiated.  It  should  be 
administered  with  caution. 

The  introducers  assert  that  75  grains 
will,  in  a  dog  of  2  '/i  pounds'  weight,  pro- 
duce symptoms  of  intoxication  followed 
by  a  most  profound  sleep  in  which  all 
sensibility  is  lost,  although  the  reflex 
activities  are  greater  than  normal.  Upon 
the  circulation  the  drug  has  but  little 
power,  the  arterial  pressure — even  when 
there  is  profound  unconsciousness — being 
scarcely  affected.  During  unconscious- 
ness not  only  is  the  motor  side  of  the 
spinal  cord  more  active  than  normal,  but 
the  cerebral  cortex  was  also  found  to  be 
extremely  excitable.  H.  C.  Wood 
("Princ.  and  Prac.  of  Therap.,"   '94). 

The  toxic  dose  is  about  Vioooo  of  the 
body-weight.  When  injected  into  a  frog 
in  this  proportion  produces  a  condition 
similar  to  that  observed  after  removal  of 
the  cerebral  hemispheres.  Spontaneous 
movements  are  abolished,  but  reflex  and 
automatic  actions  remain  intact.  Soon 
afterward,  however,  respiration  is  par- 
alyzed, followed  by  the  disappearance  of 
all  reflex  activity,  and  the  animal  lies 
apparently  dead;  but  on  opening  the 
thorax  the  heart  is  found  beating  quite 
vigorously,  this  cardiac  action  continuing 
for  two  or  more  hours  after  the  abolition 
of  the  respiratory  movement.  The  sleep 
produced  in  man  is  sometimes  preceded 
by  muscular  tremors  or  simple  twitch- 
ings,  dizziness,  and  difficulty  of  speech; 
the  sleep  i.s  more  profound  than  normal, 
the  patient  becomes  insensible  to  pinch- 
ing or  pricking  of  the  skin,  and  the 
corneal  reflexes  seem  to  be  absolutely 
abolished.  Chambard  (Revue  de  Mfide- 
cine,  Apr.  10,  '94). 

The  respiration  is  slowed,  and  by  large 
doBcs  its  rhythm  is  somewhat  altered. 
Cappelletti  (Uniao  MM.,  Sept.,  '94). 

Chloraloflc  is  a  prompt  and  safe  hyp- 
notic;   it   acts   more   rapidly    than   any 


drug  except  morphine.  It  is  also  more 
prompt  and  etBcient  in  smaller  doses 
than  chloral.  Five  grains,  the  maxi- 
mum dose,  may  be  repeated  in  an  hour. 
Nine  cases  of  insomnia  referred  to,  some 
of  them  exceedingly  severe,  in  which 
sulphonal,  trional,  and  other  hypnotics 
prove  ineffective.  Chloralose  produced 
excellent  results.  James  Tyson  (Jour. 
Amer.  Med.  Assoc,  Apr.  6,  1901). 

The  action  of  chloralose  is  chiefly 
upon  the  brain  and  the  spinal  cord. 
On  the  brain  it  causes  two  effects,  one 
of  depression  and  one  of  excitability, 
the  former  intense  and  lasting,  the  lat- 
ter slight  and  fugacious.  The  depres- 
sant action  presents  itself  as  sleep  and 
sedation;  the  sleep  comes  rapidly,  is 
exceptionally  preceded  by  intoxication; 
heaviness  of  the  head,  stupor,  or  mod- 
erate cephalalgia,  this  being  often  quite 
marked,  but  not  exaggerated;  at  other 
times  lassitude,  feebleness  of  the  lower 
extremities,  and  various  other  troubles 
on  different  days,  the  narcosis  being  fol- 
lowed by  a  feeling  of  well-being.  The 
drug  also  has  the  peculiar  property  of 
causing  physical  blindness;  it  is  capable 
of  producing  dilatation  of  the  pupil  and 
diminution  of  visual  -acuteness,  some- 
times accompanied  with  diplopia.  It  in- 
creases the  appetite  markedly,  and  ex- 
ceptionally may  cause  gastric  disturb- 
ances, eructations,  thirst,  and  vomiting. 
It  does  not  produce  an  increase  in  the 
amount  of  urine  secreted,  but  causes  a 
relative  polyuria  immediately  after  its 
administration.     (Montyel.) 

Toxic  symptoms  observed  in  two  pa- 
tients: one  sufl'ering  from  diabetes,  the 
other  from  uterine  flbroid,  the  symptoms 
being  trembling,  starting,  nausea,  vomit- 
ing, a  species  of  dull  restlessness  accom- 
panied by  incoherence,  and  involuntary 
evacuation  of  urine  and  ficces.  Touve- 
naint  (Le  Prog.  MOd.,  No.  19,  '94). 

Three  gi'ains  of  the  drug  produced 
poisonous  symptoms  in  a  child  of  0 
years:  there  was  trembling,  convulsions, 


CHLORAL  PREPARATIONS.    CHLOllETONE. 


61 


and  later  a  cataleptiform  condition  which 
lasted  two  hours.  Bardet  (Le  Bull.  M6d., 
Feb.  18,  '94). 

Nocturnal  paralysis  followed  a  dose  of 
3  grains  administered  to  an  adult.  FCrfi 
(Rev.  Neurolog.,  No.  6,  '94). 

Trembling  and  intellectual  stupor  ob- 
served in  adults.  Morel-Lavalliie  (Le 
Bull.  M6d.,  Feb.  7,  '94);  Villeprand 
(ihid.);  Talamon  (La  M6d.  Mod.,  Jan. 
27,  '94). 

Complete  loss  of  memory  in  one  in- 
stance after  the  ingestion  of  4  grains; 
intense  prurigo  as  the  result  of  a  like 
dose  in  another;  symptoms  of  paresis 
with  threatened  asphyxia  in  a  third. 
Lombroso  (Riforma  Med.,  No.  131,  '93). 
The  ingestion  of  4  grains  of  chloralose 
in  two  hours  induced  complete  insensi- 
bility and  coma;  the  pulse  was  180,  the 
heart-beats  imperceptible,  face  and  ex- 
tremities cyanosed,  epileptoid  movements 
of  limbs,  and  cold  perspiration.  Death 
seemed  imminent.  Rendu  (Le  Bull.  Med., 
Mar.  10,  '95). 

Five  or  six  similar  cases  were  published 
in  La  Mfidecine  Moderne  during  1894. 
Several  were  reported  to  the  SociC't6  de 
Th6rapeutique.  Russian  physicians,  not- 
ably Chemelewski,  added  to  the  category. 
Herzen  (Kevue  MCd.  de  la  Suisse  Rom., 
June  20,  '95) ;  Delabrosse  (La  Nor- 
mandie  MiSd.,  No.  15,  '95) ;  and  Dufour 
(Marscille-m6d.,  Dec.  15, '95)  corroborate 
as  the  result  of  personal  experiences. 

The  drug  has  one  very  important  defect 
in   that   it   occasionally   provokes   toxic 
symptoms,    which    manifest    themselves 
by  an  exaggeration  of  the  reflex  excita- 
bility of  the  medulla  oblongata,  amount- 
ing almost  to  convulsions;   in  addition 
to  this,  it  is  very  difficult  to  decide  upon 
the  proper  dose,  as  its  action  varies  not 
only  in  different  persons,  but  even  in  the 
same  person.    Foster    ("Prac.  Tlierap.," 
vol.  i,  '9G). 
Chloral-hydrocyanaie  has  the  action  of 
the  cyanides;  it  is  about  one-seventh  as 
strong  as  prussic  acid.    It  is  an  excellent 
preservative    of   solutions    intended    for 
hypodermic  use. 

Chloral-caffeine  has  been  introduced 
for  the  treatment,  hypodermically,  of 
sciatica  and  other  rheumatic  affections, 


and  all  cases  of  irritation  of  the  periph- 
eral nervous  system.  It  has  been  em- 
ployed subcutaneously  in  doses  of  from 
2  to  5  grains,  and  is  said  to  be  painless. 
Its  physiological  action  has  not,  as  yet, 
been  definitely  worked  out. 

Chloral-carbamide,  or  chloral-urethane, 
is  hypnotic,  partakes  of  the  action  of 
chloral-hydrate,  but  is  uncertain  in  ef- 
fects, disagreeable  to  take,  and  is  often 
followed  by  nausea  and  disorder  of  di- 
gestion. 

Hypnal,  or  chloral-antipyrine,  has 
all  the  properties  of  chloral-hydrate,  in- 
cluding all  the  objectionable  features  of 
the  latter,  and  depresses  the  heart  more 
seriously.  It  is  claimed  that  the  anti- 
pyrine  renders  it  analgesic,  and  there- 
fore will  induce  sleep  in  the  presence  of 
pain;  but  such  action  is  uncertain  and 
ephemeral. 

Butyl-hypnal  apparently  differs  in  no 
way  from  the  preceding. 

Chloretone,  a  new  preparation,  is  solu- 
ble to  the  extent  of  1  per  cent,  in  cold 
water.  It  is  an  hypnotic  and  an  anal- 
gesic, a  l-per-cent.  solution  being  equal 
to  a  4-per-cent.  solution  of  cocaine.  The 
customary  dose  is  from  6  to  18  grains, 
but  there  is  a  case  on  record  in  which 
108  grains  were  taken  at  one  time,  which 
had  no  other  effect  than  to  cause  the 
patient  to  sleep  for  about  three  days. 
Chloretone  passes  unmodified  from  the 
digestive  tract  to  the  blood.  (R.  TV. 
Wilcox.) 

Chloretone  has  little  or  no  effect  upon 
tlie  pulse,  respiration,  and  blood-pressure 
for  hours,  but  eventually,  if  the  dose  be 
large  enough,  these  become  depressed  and 
the  animal  dies,  the  heart  stopping  be- 
fore respiration.  Chloretone  has  a  pro- 
foundly depressing  effect  upon  the  body- 
temperature,  lowering  this  more  than 
any  otlier  drug,  with  the  possible  excep- 
tion of  alcohol.  This  depressing  effect 
is  evident  before  the  nnimnl  is  even 
drowsy,  and  is  in  ratio  to  the  dose  given. 


62 


CHLORAL  PKEPARATIONS.    UNTOWARD  EFFECTS. 


It  may  be  partially  prevented  by  keep- 
ing the  animal  very  warm.  Any  drug 
which  can  exert  such  an  effect  upon  the 
total  heat  of  the  body  is  one  which  re- 
quires to  be  used  with  great  caution  in 
medical  practice.  This  is  doubly  impor- 
tant, as  the  drug  is  verj'  slowly  got  rid 
of;  no  antidote,  with  the  exception,  per- 
haps, of  external  warmth,  is  known. 
Rudolph  (Can.  Pract.  and  Review,  June, 
1900). 

Chloretone  is  one  of  the  best  of  the 
hypnotics.  Usual  dose  is  from  3  to  5 
grains  at  bed-time.  It  is  best  given  dis- 
solved in  alcohol  or  whisky  and  followed 
by  a  glass  of  milk.  F.  F.  Ward  (Med- 
icine, vi,  p.  642,  1900). 

There  is  no  other  efficacious,  practical 
antiseptic  that  is  so  conspicuously  anaes- 
thetic as  chloretone,  when  applied  locally, 
and  at  the  same  time  so  utterly  devoid 
of  any  harmful  effects,  either  local  or 
constitutional.  T.  A.  Dewar  (Therap. 
Gaz.,  Feb.  15,  1900). 

Chloretone  is  especially  recommended 
as  an  hypnotic  and  local  ansesthetic. 
There  are  no  depressing  after-effects,  and 
it  is  safe  to  administer  large  doses.  Ten 
to  15  grains,  repeated  in  two  hours  if 
necessary,  is  the  usual  dose.  W.  M. 
Donald  (Ther.  Gaz.,  vol.  xvi.  No.  1,  p. 
18,  1900). 

Chloretone  is  the  safest  of  all  hyp- 
notics. It  should  be  given  in  from  15- 
to  20grain  doses  in  severe  cases,  and 
repeated  often  enough  to  produce  the 
desired  effect.  For  hypodermic  use,  a 
saturated  solution  of  chloretone  in  a 
mixture  containing  15  per  cent,  of  alco- 
hol and  85  per  cent,  of  water  is  suffi- 
ciently strong  to  produce  local  anajsthesia 
for  minor  operations.  A  still  more 
powerful  local  anajsthetic  may  be  pro- 
duced by  mixing  equal  parts  of  chlore- 
tone and  ctlier.  This  is  particularly  use- 
ful to  dentists  as  an  application  to  the 
ncrve-pulpg  when  it  is  advisable  to  re- 
move them.  W.  B.  Hill  (N.  Y.  Med. 
Jour.,  Aug.,  1900). 

Toxic  and  Untoward  Effects. — The 
toxic  and  untoward  cfTocts,  except  as  has 
heretofore  been  stated,  are  practically 
identical  to  those  of  all  chloral  deriva- 
tivcB.     It  is  believed  that  most  of  the 


untoward  results  arising  during  the  ad- 
ministration of  medicinal  doses  are  due 
to  impurities, — chlorinated  substances, — 
and,  fortunately,  such  are  rai-e.  These 
are,  for  the  most  part,  disturbances  of 
respiration,  including  dyspncea  and  par- 
tial asphyxia;  irregular  action  of  the 
heart;  irritation  of  the  conjunctiva; 
swelling  of  the  epiglottis  and  false  vocal 
cords;  icterus,  increased  jaundice;  bed- 
sores (rarely);  dimness  of  vision,  per- 
haps even  temporary  blindness;  ery- 
thematous, urticarious,  and  eczematous 
rashes,  etc. 

What  constitutes  a  poisonous  dose  is 
not  known,  since  so  small  an  amount  as 
20  grains  has  induced  fatality,  while,  on 
the  other  hand,  I  have  known  of  the 
ingestion  (by  accident)  of  480  grains 
without  any  ill  effects  succeeding. 
Death  may  arise  from  cardiac  syncope, 
from  paralysis  of  the  respiratory  centre 
with  coma  and  gradual  suffocation,  or 
from  excessive  depression  of  bodily  tem- 
perature; a  series  of  cases  are  recorded 
in  which  were  evinced  symptoms  akin 
to  blood-poisoning  with  purpuric  and 
scorbutic  eruptions,  ulceration  of  gums, 
and  great  prostration,  leading  to  death. 
Treatment  of  Poisoning. — First,  stimu- 
lants to  the  heart  and  respiration,  and, 
second,  attempts  directed  toward  in- 
creasing temperature.  Strychnine  has 
been  heralded  as  a  physiological  anti- 
dote, because  it  is  antidoted  by  chloral, 
but  this  premise  is,  unfortunately,  not 
a  safe  guide;  atropine  and  amyl-nitrite 
(by  inhalation)  are  more  reliable  agents; 
yet  strychnine  may  be  valuable  as  a 
means  of  sustaining  the  action  of  the 
heart. 

(Jase  of  a  middle-aged  man  who  was  in 
a  mental  state  bordering  on  melancholia, 
due  to  worry  and  the  use  of  alcohol. 
Choral-hydrate,  40  grains,  ami  poLaRsiuin 
bromide,  15  grains,  were  directed  every 
three  hours,  with  a  double  dose  at  bed- 


CHLORAL  PREPARATIONS.    THERAPEUTICS. 


63 


time.  Prescription  was  written  on 
Thursday,  and  the  patient  was  not  seen 
again  until  the  following  Monday.  He 
was  then  found  in  bed  with  his  knees 
and  chin  approximated;  tlie  extremities 
cold,  and  he  was  jerking  and  rolling 
about.  Breathing  was  slow  and  sterto- 
rous; pulse  was  slow  and  soft;  face  was 
ashen  gray,  with  parched  lips  and 
swollen  tongue;  there  was  marked 
stupor.  Since  the  prescription  had  been 
given  he  had  had  the  prescription  filled 
four  times,  and  had  been  drinking  half 
a  small  glassful  at  a  dose.  During  the 
time  he  had  eaten  heartily  and  had  taken 
little  or  no  alcohol.  It  is  estimated  that 
during  the  three  days  he  had  taken  no 
less  than  8  ounces  of  the  mixture,  or  640 
grains  of  chloral  and  9G0  grains  of  potas- 
sium bromide.  Recovery  was  rapid  under 
strychnine.  P.  F.  Rogers  (Med.  Record, 
Mar.  10,  1000). 

Chloralism  is  a  form  of  drug  addiction 
which  appears  to  be  more  common 
among  women.  As  in  all  other  forms 
of  drug  addiction,  some  previous  neu- 
rosis will  be  found  to  precede  the  first 
use  of  chloral.  The  sleep  which  it  pro- 
duces is  so  profound  and  followed  by  no 
unpleasant  sensations  that  it  is  repeated 
as  often  as  occasion  calls  for  it. 

Chloral  can  be  taken  secretly  for  a 
long  time  without  any  suspicion  of  its 
use.  After  a  time  the  efTect  of  its  use 
appears  in  disordered  digestion,  the  ir- 
regular heart-action,  and  the  increased 
nervousness  and  muscular  unsteadiness. 
In  persons  past  middle  life  a  form  of 
cardial  asthma  with  a  tendency  to  de- 
lirium appears.  These  and  many  other 
obscure  symptoms  finally  merge  into  de- 
lirium and  death.  Some  observers  have 
noticed  that  chloral-takers  have  pecul- 
iar blueness  of  the  extremities,  with 
venous  congestion;  also  marked  list- 
lessness  and  lack  of  energy  as  promi- 
nent symptoms  of  this  addiction.  Chlo- 
ralism is  confined  largely  to  the  more 
prosperous  classes  of  society.  This  drug 
can  be  disguised  in  many  ways  and  used 
as  a  fascinating  sleep-producer.  The 
amount  varies  from  20  to  2000  grains 
a  day.  Often  considerable  time  will 
elapse  before  toxic  symptoms  appear; 
then,  suddenly  extreme  prostration  with 


delirium  comes  on,  ending  fatally.  Sud- 
den palsies,  with  vasomotor  disturb- 
ances, hcart-faUure,  and  low  stages  of 
delirium,  should  suggest  chloralism,  par- 
ticularly if  alcohol,  opium,  cocaine,  and 
chloroform  be  excluded.  The  statement 
of  the  patient  concerning  his  condition 
is  of  no  value.  AVhere  the  history  indi- 
cated extreme  neuralgia  and  insomnia 
and  a  sudden  passing  away  of  these  con- 
ditions, the  assumption  that  chloral  is 
used  is  possible.  When  it  is  established 
that  chloral  addiction  is  present,  the 
patient  should  be  isolated  at  once  and 
placed  under  positive  restraint  and  the 
drug  withdrawn.  Alcohol,  opium,  chlo- 
roform, ether,  and  cocaine  are  all  con- 
tra-indicated as  substitutes.  Vegetable 
narcotics,  such  as  hyoscyamus,  valerian, 
lupulin,  bull-nettle,  and  others  of  this 
class,  may  be  given  as  substitutes  and 
withdrawn  at  the  earliest  moment.  Then 
comes  the  usual  tonic  treatment  of  nux 
vomica,  strychnine,  and  arsenic.  Cin- 
chona and  iron  are  also  excellent  drugs. 
The  insomnia  and  neuralgia  with  de- 
ranged nutrition  which  follow  the  with- 
drawal should  be  treated  with  baths, 
foods,  and  careful  hygienic  management 
of  all  the  functional  activities  of  the 
body.  Many  secret  remedies  for  neu- 
rotic troubles  contain  chloral,  and  de- 
cided symptoms  of  chloralism  often  ap- 
pear. Chloralism  has  been  mistaken  for 
general  paralysis,  neurasthenia,  and  hy- 
peroemia,  as  well  as  several  affections 
of  the  cord.  Many  opium  and  alcohol 
cases  are  found  to  be  complicated  ^vith 
chloral  addiction,  and  their  recovery  is 
more  difficult.  T.  D.  Crothers  (Med. 
Standard,  Aug.,  1901). 

Therapeutics. — In  convulsive  and  spas- 
modic disorders  chloral  is  undoubtedly 
one  of  the  best  remedies  in  the  materia 
medica.  It  has  been  found  useful  in 
asthma  (see  Eespiratory  Diseases); 
puerperal,  infantile,  and  general  convul- 
sions; chorea  and  epilepsy;  tetanus, 
trismus,  whooping-cough,  etc. 

Eespiratory  and  Cardiac  Diseases. 
— The  value  of  chloral  and  its  derivatives 
in  respiratory  maladies  is  not  so  appar- 


64 


CHLORAL  PREPARATIONS.    THERAPEUTICS. 


ent  as  in  many  other  classes  of  diseases, 
but  they  nevertheless  appear  to  possess  a 
certain  degree  of  utility,  especially  in 
certain  forms  of  asthma,  laryngitis,  bron- 
chitis, etc. 

In  the  sleeplessness  of  cardiac  and 
bronchial  catarrh  ehloralamid  is  particu- 
larly serviceable.  Its  influence  upon  the 
circulation  is  feeble,  and  not  at  all  in- 
jurious; hence  it  may  be  employed  in 
cardiac  maladies.  Biddle  ("Mat.  Med. 
and  Therap.,"  '96). 

Chloral-cafleine  in  doses  of  3  to  4Vj 
grains  may  be  used  hypodermically  in 
asthmatic  attacks.  Foster  ("Prac. 
Therap."  vol.  i,  '96). 

A  full  dose  of  chloral  is  often  useful  in 
a  paroxysm  of  asthma ;  the  shortness  of 
breath,  which  affects  the  emphysematous 
on  catching  cold,  also  often  yields  to  its 
influence.  When  dyspnoea  occurs  at 
night  25  to  30  grains  at  bed-time  calms 
the  breathing  and  gives  sound,  refreshing 
sleep;  but  when  the  dLfiiculty  is  con- 
tinuous, 2  to  6  grains  should  be  given 
several  times  daily.  It  is  necessary  to 
give  the  drug  with  caution  to  patients 
with  emphysema  and  bronchitis  accom- 
panied by  obstructed  circulation  mani- 
festing itself  in  lividity  and  dropsy. 
Ringer  and  Sainsbury  ("Hand-book  of 
Therap.,"  '97). 

Mental  Diseases. — Chloral  deriva- 
tives undoubtedly  have  a  special  value  in 
this  class  of  maladies  by  reason  of  their 
hypnotic  action.  Chloral-hydrate  espe- 
cially causes  sound,  refreshing,  natural 
sleep;  but  no  chloral  preparation  is  to  be 
depended  upon,  save  in  special  instances 
or  when  topically  applied,  as  an  obtund- 
ent of  pain. 

In  physical  derangements,  running  all 
the  way  from  ncrvoUH  excitability  up  to 
delirium  tremens,  puerperal  eclampsia, 
acute  mania  and  tetanus,  in  nervous 
asthma  and  hiccough,  chloral-hydrate  is 
an  excellent  remedy.  Roth  ("Mod.  Mat. 
Med.,"  '9.5). 

In  eighty-two  cases  of  insanity  a  sed- 
ative cfTcct  was  noticed  in  from  fifteen 


to  twenty  minutes  after  taking  chloral- 
ose;  the  most  satisfactory  results  were 
obtained  in  maniacs,  epileptics,  and  al- 
coholics. Haskovec  (Kevue  Neurolog., 
Oct.,  '95). 

Diseases  of  Kidneys  and  Genito- 
urinary Organs. — Few  seem  to  be 
aware  of  the  value  of  the  chloral  deriva- 
tives in  disease  belonging  to  the  above 
classes,  and,  perhaps,  the  most  startling 
claim  advanced  is  the  one  that  accredits 
chloral-hydrate  with  being  a  most  valued 
agent  in  the  treatment  of  ailments  char- 
acterized by  albumin  in  the  urine.  The 
evidence  of  its  value  in  urEcmia,  etc.,  is 
to  be  found  under  the  classification  of 
Spasmodic  and  Convulsive  Diseases, 
which  are  sometimes  benefited  by  this 
remedy. 

Skin  Diseases  and  Neoplasms. — 
Here  the  chloral  preparations  have  been 
greatly  employed,  and  not  without 
reason.  Chloral-hydrate,  it  is  claimed, 
if  a  strong  solution  is  painted  on  warts 
and  corns,  will  insure  their  gradual  dis- 
appearance. Chloral-hydrate,  chloral- 
ammonium,  chloral-camphor,  and  chlo- 
ral-phenol have  exhibited  some  measure 
of  value  in  the  management  of  stubborn 
skin  eruptions,  including  pruritus  and 
eczema,  and  are,  at  least,  useful  as  topi- 
cal applications  in  relieving  burning  and 
itching.  Chloral-hydrate,  in  2-  to  5- 
per-cent.  aqueous  solution  is  frequently 
effectual  in  relieving  bromidrosis  and 
hyperidrosis. 

Cholera  and  cholera  morbus  are 
maladies  in  which  chloral  compounds 
have  been  employed,  but  not  with  such 
measure  of  success  as  to  warrant  the 
practitioner's  depending  upon  them 
solely. 

Scarlatina  and  Dii'irTiiUHiA. — In 
scarlet  fever  hydrate  of  chloral  is  highly 
recommended  in  frequently-repeated 
small  doses, — say,  1  to  5  grains,  accord- 


CHLORAL  PREPARATIONS. 


CHLOROFORM. 


65 


ing  to  age;  it  has  a  marked  sedative 
effect,  controls  inflammation  both  in 
throat  and  kidneys,  and  even  tends  to 
prevent  such  sequelte  as  otitis  media  and 
glandular  swelling  and  suppuration.  In 
diphtheria  chloral-hydrate  or  chloral- 
camphor  in  suitable  solution  may  be  em- 
ployed as  a  topical  application  to  the 
throat  and  larynx,  and  the  internal  ad- 
ministration of  the  former  is  often  a 
valuable  adjunct  to  other  treatment. 

Seasickness. — Chloral  preparations 
are  widely  advised  as  a  remedy.  Though 
sometimes  efficacious,  they  often  prove 
as  futile  as  others  of  the  host  of  remedies 
that  purport  to  be  effective. 

Febrile  Maladies. — It  will  be  read- 
ily surmised  that  chloral  preparations, 
chloral-hydrate  especially,  may  find  a 
place  in  the  treatment  of  pyrexias,  not 
alone  because  of  its  sedative,  antiseptic, 
and  hypnotic  properties,  but  also  be- 
cause of  its  distinct  influence  upon  tem- 
perature. 

Chloral-hydrate  is  often  emploj-ed,  and 
very  valuably,  in  fevers,  particularly  ty- 
phoid and  tj'phus,  especially  where  want 
of  sleep,  together  with  delirium,  rapidly 
wears  out  the  strength  of  the  patient. 
Ringer  and  Sainsbury  ("Hand-book  of 
Therap.,"  '97). 

Other  morbid  conditions  in  which 
chloral-hydrate,  and  some  other  of  the 
chloral  compounds  have  been  employed 
with  varying  measures  of  success  are: 
rheumatism  and  sciatica;  as  a  dressing 
for  bed-sores  and  other  ulcers,  including 
suppurating  malignant  and  non-malig- 
nant growths,  cracked  nipples,  anal  fis- 
sure, etc.;  as  an  application  to  abort,  fel- 
ons and  boils;  for  the  vomiting  of  preg- 
nancy; for  a  purgative  action  pure  and 
simple;  and  as  a  tfenifuge  in  conjunc- 
tion with  male  fern  and  croton-oil.  The 
following  is  claimed  by  Bonatti  to  be 
a   prompt,   certain,   easily   administered 


drastic  purgative,  active  when  even  jalap 
and  croton-oil  fail: — 

J^   Infusion  of  senna,  10  ounces. 

Chloral-hydrate,  24  to  45  grains. 

Syrup,  1  ounce. — M. 

After  the  removal  of  polypi,  the  appli- 
cation of  chloral-hydrate  will  often  de- 
stroy the  base  of  the  growth.  Its  inter- 
nal administration  frequently  relieves 
the  pain  of  acute  catarrh  of  the  middle 
ear,  and  moreover  tends  to  be  remedial 
by  checking  and  reducing  inflammation. 
A  5-per-cent.  solution  is  sometimes 
useful  to  remove  granulations  in  the 
middle  ear,  especially  if  the  discharge 
is  markedly  purulent.  The  application 
of  chloral-camphor  has  sometimes  proved 
effectual  in  assuaging  the  pain  of  mas- 
toid disease. 

Vesicant  Action. — Powdered  chlo- 
ral, sprinkled  over  adhesive  plaster, 
gently  wanned  and  laid  on  the  skin, 
makes  a  speedy,  painless,  and  effective 
blister,  at  least  equal  if  not  superior  to 
cantharides  and  more  safe  as  regards 
children. 

When  a  marked  effect  is  rapidly  re- 
quired, chloral  hydrate  is  better  than 
cantharides  and  has  none  of  its  disad- 
vantages. With  children,  next  to  iodine 
it  is  the  counterirritant  of  choice.  The 
blister  will  produce  erythema,  vesica- 
tion, or  ulceration,  as  desired.  M.  T. 
Brennan  (Montreal  Med.  Jour.,  May, 
1902). 

CHLORIDE  OF  ETHYI.  See  Ethyl 
Chlohide. 

CHLOEINE.  See  derivatives:  Potas- 
sium Chlorate,  Sodium  Chloride, 
etc. 

CHXOROFORM.  —  This  well-known 
ana-sthetic  was  simultaneously  discov- 
ered, in  1831.  by  Guthrie,  of  the  United 


66 


CHLOKOFOEil.    PHYSIOLOGICAL  EFFECTS. 


States;  Soubeiran,  of  France;  and  Lie- 
big,  of  Germany.  Dumas  later  on  gave 
it  its  present  name,  and  Sir  James  Y. 
Simpson,  of  Edinburgh,  first  used  it  as 
an  anaesthetic. 

Chloroform  (ChClj;  specific  gravity, 
1.497  at  62.5°  F.)  is  a  tercliloride  of 
formyl,  obtained  by  the  action  of  chlo- 
rine upon  alcohol,  the  methods  usually 
employed  being  either  the  addition  of 
chloral-hydrate  to  an  alkaline  solution 
or  of  chlorinated  lime  to  ethyl-oxide. 
This  is  distilled  and  subsequently  puri- 
fied by  the  addition  of  sulphuric  acid, 
sodium  carbonate,  and  lime,  and  redis- 
tillation is  then  resorted  to. 

Chloroform  appears  as  a  neutral,  color- 
less fluid,  possessing  a  sweetish  and  hot 
taste,  and  giving  off  a  fragrant  and  char- 
acteristic odor.  It  possesses  marked 
solvent  powers,  rapidly  dissolving  alka- 
loids, iodine,  bromine,  volatile  oils,  etc.; 
but  is  itself  only  sparingly  soluble  in 
water.  It  is  distinctly  so,  however,  in 
alcohol  and  ether. 

Chloroform  is  not  inflammable  under 
ordinary  circumstances,  except  when 
mixed  with  alcohol.  When  used,  how- 
ever, in  the  presence  of  a  gas-flame,  it 
is  likely  to  become  decomposed,  and  the 
product  may  prove  noxious  to  the  per- 
sons inhaling  it. 

Chloroform-vapors  are  broken  up  into 
chlorine  and  carbonic  oxide  by  gaslight, 
causing  bronchial  irritation  in  those 
present,  asphyxia  in  the  patient,  and 
even  death.  Herson-Leidon  (Deutsche 
med.  Woch.,  Apr.  3,  '90). 

Hydrochloric  acid  and  carbon  dioxide, 
and  not  monoxide,  are  the  toxic  agents. 
Kunkel  (MUnch.  med.  Woch.,  Apr.  4, 
'90). 

A  coal-gas  flame  in  an  ill-ventilated 
room  and  a  somewhat  prolonged  exhibi- 
tion of  chloroform  may,  by  forming  a 
compound  with  the  latter,  induce  serious 
symptoms  in  patient,  surgeon,  and  assist- 
ants.   Illustrative  instances.    Charles  G. 


Lee  (Liverpool  Medico-Chir.  Jour.,  July, 
'95). 

Identical  efl'ects  observed.  Irritating 
agent,  a  carbon-oxychloride,  or  phosgene, 
discovered  by  Sir  Humphry  Davy.  Pat- 
erson  (Practitioner,  vol.  xlii). 

Warning  against  use  of  chloroform 
near  a  gaslight,  ethylene-chloride  being 
thereby  formed.  In  tabetic  patients  fatal 
coma  may  be  induced.  Eehn  (Le  Bull. 
Med.,  May  12,  '95). 

Case  of  a  man  shot  in  the  abdomen, 
who  was  brought  to  the  hospital  at  night 
and  immediately  operated  upon  by  gas- 
light. As  a  result  of  the  chloroform 
narcosis,  which  had  to  be  kept  up  for 
four  hours,  powerful  chlorinated  vapors 
were  produced.  Two  of  the  surgeons 
and  several  of  the  Sisters  of  Mercy  were 
overcome  and  one  of  the  latter  has  since 
died.     (Inter.  Med.  Mag.,  Apr.,  '98.) 

The  administration  of  chloroform  while 
artificial  lights  are  burning  is  likely  to 
produce  broncho-pneumonia  and  cedema 
of  the  lungs,  with  marked  passive  con- 
gestion of  the  liver  and  kidneys.  This 
variety  of  poisoning  also  occurs  with 
some  frequency  in  druggists  and  chemists 
wlio  use  chloroform  in  the  presence  of 
gas-flames.  Kenelm  Winslow  (Boston 
Med.  and  Surg.  Jour.,  May  11,  '99). 

Even  under  ordinary  conditions  the 
chloroform  usually  employed  for  anaes- 
thetic purposes  tends  to  decompose  and 
to  form  hydrochloric  acid  and  carbonyl- 
chloride.  According  to  Newman  and 
Ramsay,  this  latter  substance  is  the  cause 
of  the  majority  of  cases  of  after-sickness. 
This  can  be  overcome  by  keeping  a  little 
slack  lime  in  the  bottles  and  filtering  in 
the  supernatant  liquid  as  required. 

The  deleterious  effects  of  chloroform 
become  especially  manifest  when  kept 
in  a  bottle  containing  air  and  exposed  to 
light. 

Physiological  Effects  and  Centra-in- 
dications.— The  conclusions  of  Lawrie 
and  of  the  Hyderabad  Commission,  the 
principal  of  which  is  that  failure  of 
respiration  is  the  only  possible  way  by 
which  death  is  produced  by  chloroform, 


CHLOROFORM.    PHYSIOLOGICAL  EFFECTS. 


67 


has  now  run  the  gauntlet  of  several  years' 
criticism  and  may  be  said  to  no  longer 
be  accepted  by  the  profession,  and  espe- 
cially by  experienced  anaesthetists.  In- 
deed, many  competent  observers  have 
reported  cases  in  which  the  heart  ceased 
before  the  respiration,  and  Mr.  Leonard 
Hill  has  recently  expressed  the  view  that 
the  cause  of  chloroform  collapse  was 
in  all  cases  a  primary  failure  on  the 
circulatory  mechanism,  the  respiration 
failing  secondarily  on  account  of  the 
auEEmia  of  the  bulbar  centres.  He  had 
examined  all  the  tracings  taken  by  the 
Hyderabad  Commission,  and  found  that 
in  them  (although  it  was  not  so  inter- 
preted by  the  experimenters)  the  same 
typical  fall  of  arterial  pressure  actually 
occurring  before  the  cessation  of  respira- 
tion observed  by  him  elsewhere.  Thus 
their  own  experimental  evidence  contra- 
dicts the  conclusions  arrived  at  by  the 
workers  on  the  said  commission. 

A  correct  view  would  probably  include 
both  factors:  a  conclusion  which  Horatio 
C.  Wood  reached  eight  years  ago,  when 
he  said:  "If  any  evidence  is  to  be  at- 
tached to  the  statements  of  competent 
witnesses  it  is  certain  that  in  some 
cases,  under  the  influence  of  chloroform, 
the  pulse  and  respiration  have  ceased 
simultaneously,  while  in  other  instances 
the  respiration  has  ceased  before  the 
pulse,  and  in  still  other  cases  the  pulse 
has  ceased  its  beat  before  the  respiratory 
movements  were  arrested."  Lauder 
Brunton  has  since  given  precision  to 
our  knowledge  by  an  exhaustive  study 
of  the  question,  which  led  him,  in  the 
main,  to  believe  that  cases  of  simple 
danger  without  death  were  due  to  failure 
of  respiration,  while  death  was  brought 
about  through  arrest  of  the  heart  or 
arrest  of  the  heart  and  respiration  to- 
gether   (neuroparalysis);     furthermore, 


that  the  most  common  cause  of  neuro- 
paralysis, as  found  by  Casper,  was  strang- 
ling (as  in  drowning),  which  kills  by 
neuroparalysis  as  often  as  by  asphyxia. 

[Variations  in  circulation  due  not  only 
to  the  above  various  factors,  but  also  to 
alterations  effected  by  chloroform  in  the 
central  nervous  system  and  local  nervous 
mechanisms.  As  shown  by  Waller,  elec- 
trical reaction  is  profoundly  altered  by 
anaesthetics;  hence  distinct  danger  in  con- 
ditions of  nerve-prostration  and  post-in- 
fluenzal  neurasthenia.  The  whole  ques- 
tion of  reflex  inhibition  of  the  heart 
under  chloroform  bristles  with  diflScul- 
ties.  If  fear  were  simply  the  cause,  such 
cases  would  occur  often  under  ether,  as 
that  substance,  when  badly  given,  pro- 
duces more  terror,  breath-holding,  and 
struggling  than  chloroform;  and  yet 
ether  seldom,  if  ever,  kills  in  this  way. 
Unquestionably,  chloroform  —  whether 
through  poisonous  effects  on  protoplasm 
or  in  some  other  way — exerts  some  dele- 
terious influence  upon  tissues  of  patients, 
which  renders  them  less  able  to  with- 
stand any  unusual  strain  imposed  upon 
them.  Dudley  Buxton^,  Assoc.  Ed.,  An- 
nual, '9G.] 

Arrest  of  the  heart  is  one  of  the  most 
important  causes  of  collapse  during 
chloroform  anaesthesia.  The  paralysis  of 
the  vasomotor  centre  which  is  provoked 
by  the  latter  brings  about  the  rapid  fall 
of  tlie  blood-pressure,  and  this  fall,  by 
depriving  the  cardiac  muscle  of  its  ex- 
citant, is  one  of  the  causes  of  the  arrest 
of  the  heart.  Evenhoff  (Vratch;  Union 
MC'd.,  July  11,  '97). 

The  principal  danger  from  chloroform 
antesthesia  is  the  sudden  syncope  from 
cardiac  paralysis,  which  is  as  likely  to 
occur  in  strong  as  in  weak  subjects;  it 
happens  more  frequently  at  the  begin- 
ning than  at  the  end  of  antesthetization, 
presents  conditions  of  the  greatest  diffi- 
culty for  treatment,  and  frequently  re- 
sults in  death.  In  view  of  these  condi- 
tions, although  the  superiority  and 
greater  convenience  of  chloroform  in  cer- 
tain cases  of  cerebral  surgery,  operations 
on  the  respiratory  passages,  etc.,  may 
give  it  preference,  its  adoption  as  a  rou- 
tine antesthetic  ought  to  be  condemned. 


68 


CHLOKOFOKM.    CONTRA-INDICATIONS. 


Editorial  (Boston  Med.  and  Surg.  Jour., 
Aug.  26,  '97). 

Out  of  some  2400  patients  ■who  were 
etherized,  10  developed  temperatures 
with  some  respiratory  complications,  and 
aU  had  gas  before  ether.  Six  of  these 
had  bronchitis,  1  pleurisy,  and  3  broncho- 
pneumonia, 1  of  these  last  being  a  fatal 
case.  Seven  of  these  cases  occurred  in 
summer.  In  none  of  these  10  cases  was 
there  previous  history  of  bronchitis;  all 
were  in  good  condition  and  took  the  an- 
aesthetic well.  The  operations  were  pro- 
longed ones,  and  with  1  exception  on  the 
trunk,  necessitating  bandaging,  which 
would  prevent  free  expectoration.  A 
number  of  patients  in  had  condition 
from  alcohol  or  sepsis,  and  subjected  to 
short  operations  under  ether  without 
gas,  did  not  develop  any  lung  complica- 
tion. These  last  patients,  however,  did 
not  have  to  traverse  corridors.  Not  one 
out  of  600  chloroform  cases,  of  which 
many  were  for  mouth  operations,  de- 
veloped any  respiratory   trouble. 

Chloroform  is  recommended  for  all 
long  operations  on  the  trunk,  or,  if 
ether  be  given  at  first,  it  should  be 
changed  after  a  time  for  chloroform. 
Crouch  and  Corner  (Lancet,  May  24, 
1902). 

Effect  produced  on  the  isolated  mam- 
malian heart  by  perfusion  of  chloroform 
when  the  chloroform  is  exhibited  not  in 
saline  solution,  but  in  the  blood  itself. 
Administered  in  physiological  saline  so- 
lution, it  depresses  the  heart's  beat  much 
more  powerfull3'  than  when  admini.stercd 
in  blood  in  the  same  percentage  strength. 
The  effect  of  chloroform  from  0.05  per 
cent,  up  to  0.1  per  cent,  in  blood  is  to 
depress  the  heart-beat  only  equivalcnlly 
to  chloroform  solutions  aliont  twelve 
times  less  concentrated  in  physiological 
saline  solution.  Byles,  Harcourt,  an  1 
Horsley  describe  their  method  of  esti- 
mating the  amount  of  chloroform  dis- 
solved in  blood.  From  their  results  tlicy 
infer  that  the  retaining  power  of  the 
blood  for  chloroform  is  also  associated  In 
some  degree  with  the  integiity  of  the 
corpuscles  at  the  time  of  entry  of  the 
chloroform  into  the  blood.  Sherrington 
and  Sowton  M'.rit.  Med.  .Jour.,  .Tuly  23, 
1004). 


The  heart  also  shares  the  brunt  of 
responsibility  with  the  respiratory  tract 
as  far  as  contra-indications  are  con- 
cerned; bnt  if  the  operator  bears  in 
mind  the  fact  that,  the  nearer  muscular 
integrity  of  the  organ  is  discerned,  the 
greater  the  safety,  he  will  at  once  have 
a  key  to  the  lesion  which  may  prove  tlie 
basis  of  complications.  Fatty  degenera- 
tion and  dilatation  are  the  main  condi- 
tions to  fear,  because  the  cardiac  walls 
are  the  most  compromised  and  may  not 
be  able  to  resist  the  engorgement  result- 
ing from  increased  arterial  pressure. 

Valvular  lesions  only  increase  the  dan- 
ger if  they  are  obstructive.  In  that  case, 
even,  compensative  hypertrophy  may  also 
compensate  for  the  extra  resistance  in- 
duced. 

In  aortic  insufficienc)',  as  emphasized 
by  Giffen,  it  is  necessary  to  study  heart- 
rhythm  and  arterial  pressure.  So  long  as 
the  rapidity  of  the  heart's  action  does  not 
disturb  the  rhythm — viz.:  first  sound, 
second  sound,  pause — within  reasonable 
physiological  limits,  or,  in  other  words, 
the  arterial  pressure  (composed  of  the 
time  [rapidity]  and  intensity  [muscular 
impulse])  does  not  overcome  rhythm, 
the  anassthetic  can  be  given  without  in- 
creased danger. 

Phj'sicians  and  surgeons  are  agreed 
that  accidents  in  chloroform  anresthesia 
are  not  more  frequent  in  patients  with 
aortic  or  heart  disease  than  in  patients 
with  other  illness.  Nor  does  cardiac  or 
aortic  disease  contra-indicate  chloroform 
as  an  anaesthetic,  if  the  disease  is  not 
acute  and  infectious,  if  the  patient  is  not 
too  feeble,  or  if  dyspnoea,  asystole,  or 
symptoms  of  pericardial  symphysis  have 
not  appeared.  In  some  eases  of  atheroma 
and  cardiac  disease  the  heart  condition 
even  improved  after  chloroformization. 
The  main  conlra-indication  to  chloro- 
form in  patients  with  heart  disease  is 
the  presence  of  dyspnoea.  This  is,  how- 
ever, but  temporary.    Accidents  may  be 


CHLOROFORM.    CONTRA-INDICATIONS. 


69 


due  to  impure  chloroform,  or  may  oc- 
cur under  chloroform,  yet  may  not  be 
due  to  the  chloroform.  The  question 
whether  etlier  or  chloroform  is  to  be 
preferred  as  the  anoesthetic  has  not  yet 
been  definitely  settled.  Ether  is  to  be 
preferred  in  nervous  patients,  with  kid- 
ney disease,  low  arterial  tension,  pro- 
found anjemia,  and  depression.  It  is 
contra-indicated  in  pulmonary  disease, 
dyspnoea,  etc.  Ethyl  bromide  has  been 
given  first  by  Richelot  with  success,  fol- 
lowing with  chloroform  after  anaesthesia 
has  begun.  Laborde  advises  atropine, 
morphine,  and  sparteine,  hypodermically, 
before  chloroformization.  Pure  chloro- 
form, well  given,  to  a  patient  prepared 
for  it,  almost  never  kills.  Henri  Hu- 
chard  (Jour,  des  Praticiens,  May  31; 
Phila.  Med.  Jour.,  Sept.  13,  1902). 

Disorders  of  the  respiratory  tract  are 
as  liable  to  compromise  the  issue  as  any 
grave    cardiac    disease.      Great    caution 
should  be  observed  in  the  administration 
of  chloroform   in   all   asphyxial   condi- 
tions,— i.e.,  when  the  respiratory  area  is 
to  any  degree  restricted  through  the  pres- 
ence of  growths,  pysemic  accumulations, 
emphysema,  etc.    In  scrofulous  children 
the    presence     of     enlarged    bronchial 
glands  is  to  be  surmised,  and  the  anaes- 
thetic should  be  administered  with  un- 
usual care.    In  affections  complicated  by 
liquid    effusions,    however,    the    danger 
may  be  thwarted  when  it  presents  itself. 
Case  showing  what  timely  evacuation 
of  contents   of   pleura  will   do   in   such 
cases.    As  soon  as  evidences  of  asphyxia 
showed  themselves  the  skin  was  divided 
with  one  cut  of  bistoury  and  the  pleura 
was  instantly  opened  and  pus  evacuated, 
the  almost  moribund  patient  quickly  re- 
turning to  life.    Guermonprcz  (Jour,  des 
Sciences  MC-d.  de  Lille,  May  4,  '95). 

Fatal  accidents  during  administration 
of  chloroform  are  especially  liable  to  oc- 
cur in  persons  with  the  lymphatic  con- 
dition, enlarged  thymus,  etc.  F.  Strass- 
mann  (Berliner  Klinik,  Feb.,  '98). 

Langlois  and  Eicliet  have  shown  by 
experiments  on  animals  that  in  surgical 


anaesthesia  extreme  care  should  be  taken 
that  the  movements  of  expiration  be  not 
interfered  with.  This  might  be  extended 
to  expiration,  likewise,  and  the  necessity 
of  protecting  the  via  vilcB  against  the 
ingress  of  mucus,  saliva,  blood,  etc.,  thus 
emphasized. 

Following  remarks  founded  on  0657  ad- 
ministrations of  anaesthetics  at  London 
Hospital.    Other  things  being  equal,  the 
stronger  the  patient,  the  more  trouble 
with  the  anaesthetic.  Deaths  from  chloro- 
form are  more   common  in   the  middle 
period  of  life,  and  more  men  than  women 
die  from  this  agent.   Chloroform  is  more 
dangerous  during  the  early  stages  of  ad- 
ministration; respiration  should  be  care- 
fully watched,  and  every  breath  should 
be  both  heard  and  felt.     Watching  the 
chest  or  abdomen  is  a  fallacious  guide. 
Obstructed  breathing  is  best  relieved  by 
unlocking  the  teeth  and  pushing  the  jaw 
forward.  There  were  13  cases  in  the  6657 
administrations  in  which  the  threatening 
symptoms    occurred.      When    dangerous 
symptoms  arise  during  or  after  the  use 
of  an  anaesthetic,  one  or  more  of  four 
factors  may  be  responsible:    first,  the 
anaesthetic  itself;   second,  the  condition 
of  the  patient;  third,  the  posture  of  the 
patient;  and,  fourth,  the  surgical  opera- 
tion.   W.  Hewitt  (Lancet,  Feb.  19,  '98). 
Attention  has  been  called  to  the  im- 
portance of  examining  the  urine,  espe- 
cially for  albumin,  before  subjecting  a 
patient  to  a  general  ansesthetic,  and  par- 
ticularly in  subjects  of  middle  or  ad- 
vanced age,  whose  appearance  suggests 
the  presence  of  renal  disease.     Whether 
the  presence  of  albumin  in  the  urine 
should  prohibit  any  surgical  operation  is 
a  mooted  point.    Snow  laid  it  down  as  an 
axiom  that,  if  an  operation  must  be  per- 
formed, however  serious  it  might  be,  the 
administration    of    an    anaesthetic    was 
justifiable,  on  the  whole,  and  that  rule 
has  been  pretty  generally  adopted  with- 
out any  manifest  bad  results.    Benjamin 
Ward  Richardson,  referring  to  the  above, 
stated  that  he  had  administered  ether, 


70 


CHLOROFORM.    CONTRA-INDICATIONS. 


chloroform,  and  methylene  to  great  num- 
bers of  persons  suffering  from  albuminu- 
ria, without  any  untoward  results. 

The  marked  increase  of  albumin  noted 
in  albuminuric  cases  and  the  presence  of 
it  in  cases  which  had  not  shown  any  be- 
fore the  administration  of  the  anaes- 
thetic shown  in  the  following  abstracts, 
nevertheless  counsel  prudence. 

It  seems  obvious  that  renal  lesions  can 
but  cause  increased  blood-pressure,  and 
thus  tend  to  enhance  the  likelihood  of 
cardiac  syncope,  and  that,  when  kidney 
lesions  are  known  to  exist,  chloroform 
should  be  administered  with  unusual  pre- 
caution. 

The  urine  of  one  hundred  male  pa- 
tients studied  before  and  after  chloro- 
form narcosis.  Tlie  alteration  of  the  kid- 
ney is  a  tissue-lesion  which  removes  the 
power  of  inhibiting  the  loss  of  serum- 
albumin,  the  causes  of  which  lie  in  the 
poverty  of  0X3-gen  in  the  blood,  the  de- 
struction of  blood-corpuscles  by  the  chlo- 
roform, the  injury  to  the  tissues  by  the 
liberated  chlorine,  and,  lastly,  the  lower- 
ing of  blood-pressure.  As  evidence  for 
the  occurrence  of  a  tissue-lesion,  the  fact 
was  adduced  that  in  44  out  of  56  cases 
investigated  upon  this  point,  after  nar- 
cosis, the  urine  contained  nucleo-albu- 
min.  V.  Friedliinder  (Viertel.  f.  ger. 
Med.,  Dritte  Folge,  B.  8,  Supplement,  H., 
p.  94). 

After  prolonged  chloroform  narcosis  in 
healthy  persons  there  is  prolonged  dis- 
turbance in  metabolism  of  albuminous 
substances.  Kast  and  Hester  (Zeit.  f. 
klin.  Med.,  vol.  xviii,  '95). 

Result  of  a  study  of  two  hundred  and 
fourteen  cases  of  chloroform  aniestliesia 
in  which  the  urine  was  carefully  exam- 
ined. Albuminuria  occurred  in  80  per 
cent,  of  the  eases,  lasting  from  two  to 
six  days.  Sugar  and  acetone  were  never 
found.  In  60  per  cent,  casts  were  pres- 
ent, mostly  hyaline,  but  also  a  few 
cpitlieliul  and  granular.  All  degrees  of 
changes  were  found  in  the  kidneys,  from 
single  hypcricmia  and  capillary  hicmor- 
rhagcB  to  extensive  coagulation  necrosis 


of  the  renal  epithelium.  K.  Ajello  (Mon- 
ograph, Milan,  '96). 

Examination  of  the  urine  in  130  cases 
of  anfesthesia, — 60  from  ether  and  70 
from  chloroform.  In  8  cases  out  of  13 
in  which  there  was  albumin  in  the  urine 
before  the  anfesthesia  there  was  an  in- 
crease of  the  albuminuria :  4  times  after 
ether  and  4  times  after  chloroform. 
Eisendrath  (Deut.  Zeit.  f.  Chir.,  B.  40, 
'96). 

Effects  of  ether  and  chloroform  nar- 
cosis on  the  kidneys.  In  29  per  cent,  of 
the  cases  after  etherization  albumin  was 
found  in  the  urine,  and  in  18.89  per  cent, 
after  chloroform  narcosis.  In  each  ease 
the  urine  before  the  operation  was  free 
from  any  trace  of  albumin.  The  ether- 
ized animals  showed  renal  alterations 
consisting  of  diffuse  hfemorrhagie  nephri- 
tis, with  preponderating  glomerulitis  and 
multiple  renal  haemorrhages.  The  su- 
periority of  ether  over  cliloroform  from 
the  point  of  view  of  safety  is  shown. 
Babacci  and  Bebi  (II  Policlin.,  May  1,  '96). 

Examination  of  the  urine  of  54  people 
after  chloroform  anajsthesia,  and  of  41 
cases  after  ether  anassthetization.  Nar- 
cosis in  chloroform  cases  lasted,  on  an 
average,  57  minutes,  and  in  the  ether 
cases  one  and  a  half  hours.  There  were 
10  cases  of  albuminuria  and  cylindruria 
after  chloroform;  15  cases  after  ether. 
In  3  of  this  last  series  there  was  pre- 
existing kidney  disease.  Autopsy  in  2 
ether  cases  showed  ha;morrhagic  nephri- 
tis affecting  especially  the  glomeruli.  Al- 
bumin is  more  frequently  observed  in 
the  urine  after  ether  than  after  chloro- 
form, but  the  nephritis  caused  by  ether 
is  transitory,  while  that  due  to  chloro- 
form is  likely  to  become  chronic.  Le- 
grain  (Ann.  des  Mai.  dcs  Org.  Genito- 
Urin.,  No.  2,  p.  191,  '97). 

Permeability  of  the  kidneys  after 
chloroform  narcosis  tested  with  solution 
of  rose  aniline.  As  a  rule,  it  took 
twenty-four  hours  to  get  rid  of  all 
traces  of  the  pigment,  the  patient  hav- 
ing, as  far  as  was  known,  healthy  kid- 
neys. In  every  case  elimination  was  de- 
layed by  chloroform  anresthesia;  while 
it  took  thirty-five  hoTirs  to  eliminate 
the  pigment  before  chloroform,  in  one 
case  it  required   foi'tyone  hours  after- 


CHLOROFORJI.    CONTRA-I^^)ICATIONS. 


71 


ward.  No  constant  relation  between 
the  quantity  of  chloroform  and  dura- 
tion of  the  anaesthesia  and  the  altera- 
tion in  renal  function  could  be  detected, 
as  the  personal  equation  of  the  kidney 
varies  so  much.  The  quantity  of  urine 
after  chloroform  narcosis  was,  for  the 
most  part,  reduced.  Benassi  (Gazz. 
degli  Osped.,  Mar.  3,  1901). 

If   pieces   of   kidneys   taken   from   an 
animal   that  died  from   chloroform   are 
hardened  and  fi.xed  b}'  proper  reagents, 
the  border  of  the  epithelial  cells  in  the 
convoluted  tubes  is  destroj'cd.     This  is 
of  extreme  importance,  as  the  border  of 
the  epithelial  cells  is  to  the  kidney  what 
the  rods  and  cones  are  to  the  eye,  which 
being  destroyed  will  render  the  eye  blind. 
The  kidney  therefore  losing  that  border 
can  no  more  serve  as  a  filter.    The  in- 
tegrity  of   the   epithelial   cells   is   abso- 
lutely indispensable  for  a  good  function 
of  the  kidneys.     Twenty-five  years  ago 
Heidenhain  attributed  to  those  cells  the 
property  of  eliminating  urea.     We  know 
now  that  the  function  of  the  cells  with 
their  intact   border  is   secretion.     They 
extract  from  the  blood  certain  products. 
The    renal   secretion   will   therefore   de- 
pend upon  the  integrity  of  the  cells  of 
the  tubules.     This  important  function  is 
impaired  by  chloroform,  when  adminis- 
tered as  an  anresthetic,  but  the  cell  is 
capable  of  recuperating.     Renaut  (Jour, 
des  Praticiens,  No.  15,  1902). 
The  inhibiting  influence  of  cliloroform 
narcosis   upon   general   metabolism   has 
been  considered  as  a  prominent  factor  in 
the    etiology    of   untoward    phenomena, 
and  Guthrie  and  Kiefer  have  ascribed 
some  deaths  occurring  some  days  after 
the  administration  of  the  anaesthetic  to 
defective  elimination  of  excretory  prod- 
ucts.     Casper,    Behrend,    Langenbeck, 
and  other  authorities  have  shown  that 
chronic  chloroform  poisoning  does  act- 
ually occur;    and   Guthrie  ascribed   to 
autointoxication:    either  a  fatty  condi- 
tion of  the  liver  (and,  therefore,  func- 
tional disturbance  of  the  organ)  exist- 
ing before  the  anaesthetic  was  given,  or 
to  chloroform  and  operation-shock  com- 


bined, which  aggravated  the  condition 
already  present.  It  is  supposed  that 
lessened  oxidation,  such  as  some  believe 
ether  and  chloroform  can  cause,  leads 
to  deposition  of  fat  in  the  liver  and  else- 
where, and  so  would  prevent  fat  being 
oxidized  on  its  way  from  the  liver  into 
the  general  circulation. 

Chloroform  decomposes  blood  in  pres- 
ence of  an  alkali  and  liberates  carbonic 
monoxide;    also  in  the  bodj'  in  alkaline 
blood.    This  may  account  for  some  deaths 
from  chloroform.     Desgrfs  and  Nicloux 
(Jour,  of  Amer.  Med.  Assoc,  Jan.  29, '98). 
Chloroform  may  cause  death  several 
days  after  administration,  from  causes 
which    are    at   present    unknown.      The 
changes  found  in  such  cases  after  death 
chiefly  consist  in  fatty  degeneration  of 
the  heart-muscle,  of  the  liver,  and  of  the 
kidneys.      The    degeneration,    although 
usually  present  in  several  of  these  organs, 
is  more  often  specially  localized  in  one 
or  other;    the  resulting  clinical  features 
vary  accordingly.     The  degeneration  in 
question  is  analogous  to  that  observed 
in    animals    dying   from    long-continued 
chloroform  ansesthesia.  Salen  and  Wallis 
(Centralb.  f.  Chir.,  Aug.  19,  '99). 
Ungar,  Strassmann,  and  other  observ- 
ers have  also  found  that  fatty  changes 
could  be  induced  in  the  liver  through 
the   influence   of  chloroform  upon  the 
blood-vessels  and  tissue-cells.     As  a  re- 
sult,   the    urine    becomes    loaded    with 
alkaloidal  bodies  which  the  kidneys  can- 
not  eliminate   with   suflicient   rapidity. 
Hence  the  autointoxication. 

As  a  result  of  chloroform  narcosis 
there  are  present  fatty  degeneration  of 
organs,  especially  fatty  infiltration  of  the 
liver  and  fatty  changes  in  the  cardiac  and 
skeletal  muscles,  kidneys,  and  stomach; 
these  fatty  changes  arise  from  the  action 
of  chloroform  upon  the  blood-corpuscles 
and  tissue-cells.  Some  subjects  show  a 
greater  susceptibility  to  these  effects  of 
chloroform  than  others.  Chloroform  is 
contra-indicated  in  all  cases  of  fatty 
liver;  whenever  this  condition  is  not 
discoverable  by  clinical  evidence,  the 
fact  that  the  liver-function  is  hampered 


72 


CHLOROFOKM.    METHOD  OF  ADinXISTKATION.    POSITIONS 


— as  shown,  for  example,  by  alkaloidal 
bodies  in  the  urine — should  be  taken  as 
eontra-indicative  to  ehloroform.  Ungar 
and  Strassmann,  Thiem,  and  Fischer 
(Deutsche  med.  Zeitung,  p.  4,  '89) ;  Os- 
tertag  (Virchow's  Archiv,  vol.  cxviii, 
p.  2). 

After  death  from  chloroform  there  is 
a  decided  acid  reaction  of  the  fluids  and 
tissues,  and  the  lessening  in  alkalinity 
actually  occurs  during  chloroform  in- 
halation. Taken  in  connection  with  the 
researches  of  East  and  Hester,  showing 
that  fatty  degeneration  follows  pro- 
longed inhalation,  this  possibly  explains 
the  lethal  effects  that  chloroform  exerts 
on  the  cells.  The  urine,  further,  has  its 
acidity  increased  after  chloroform.  It 
would  appear  as  if  the  acid  excretions  of 
the  working-muscles,  etc.,  usually  readily 
neutralized  by  the  cells  (Langendorfif ), 
are  left  unaltered,  or  are  imperfectly  neu- 
tralized during  chloroform  inhalation. 
Slansfelde  (Omaha  Clinic,  Sept.,  '92). 

Method  of  Administration. — Position. 
— The  position  of  the  patient  bears  an 
important  influence  upon  the  results. 
When  the  splanchnic  vasoconstrictors 
are  paralyzed  by  injuries  or  poisons,  such 
as  chloroform,  the  influence  of  gravity 
becomes  manifest,  as  shown  by  Leonard 
Hill,  owing  to  dilatation  of  the  abdomi- 
nal veins  with  corresponding  emptying 
of  the  heart  and  cessation  of  cerebral 
circulation;  hence  the  numerous  acci- 
dents reported  witnessed  in  the  dental 
position;  that  is  to  say,  that  employed 
by  dentists  for  the  removal  of  teeth. 
Death  in  sitting  posture  occurs  from 
Budden  cessation  of  the  heart's  action, 
through  abdominal  engorgement  and  de- 
pletion of  cerebral  vessels. 

Two  cases  in  which,  through  extensive 
injuries  of  cranium,  large  areas  of  brain 
proper  were  exposed.  Under  prolonged 
anffHthesia,  chloroform  reduced  cerebral 
circulation.  Tn  one  case  in  which  the 
local  hffimorrhage  was  severe  the  latter 
HubHidcd  as  soon  as  patient  was  fully 
under  anjesthctic.  Bedford  Brown  (Ther. 
Gaz.,  Dec.  15,  '94). 


The  use  of  chloroform  and  ether  is 
always  dangerous  in  ordinary  dental  sur- 
gery, and  is  unjustifiable.  Nitrous-oxide 
gas  is,  by  far,  the  best  dental  anaesthetic. 
H.  Sewill  (Archives  of  Otology,  Dee.  S, 
'94). 

For  operations  about  the  mouth  or 
throat  full  extension  of  the  head  upon 
the  trunk,  while  the  patient  is  lying 
down,  answers  admirably,  but,  as  shown 
by  Buxton,  it  produces  some  congestion 
of  the  head  and  neck  vessels,  which  in 
certain  subjects  induces  a  very  undesir- 
able amount  of  bleeding.  If  the  exten- 
sion is  not  exaggerated,  however,  and  if 
the  head  is  supported  beyond  the  edge  of 
the  table  so  that  the  traction  upon  the 
anterior  portion  of  the  neck  through  an 
excessive  extension  is  not  too  great,  the 
abnormal  bleeding  can  be  avoided.  For 
the  removal  of  adenoid  vegetations  this 
position  is  of  value.  In  the  illustration 
shown  herewith,  while  the  general  posi- 
tion of  the  patient  is,  on  the  whole,  the 
proper  one,  the  head  is  unduly  forced 
downward.  A  small  pillow  or  three  or 
four  towels  adjusted  to  the  edge  of  tlie 
table  to  support  the  head  somewhat 
higher  would  place  the  patient  within 
easy  reach  of  the  surgeon  and  at  tlie 
same  time  avoid  the  danger  of  excessive 
bleeding. 

For  operations  in  the  vault  of  the 
pharynx,  as  in  the  case  of  adenoid 
growths,  the  blood  is  thereby  prevented 
from  flowing  in  the  direction  of  the 
larynx:  an  element  of  danger,  in  many 
cases,  when  the  position  of  the  body  is 
on  a  line  to  that  of  the  region  operated 
upon. 

Dudley  Buxton  calls  attention  to  the 
fact  that  the  lateral  position,  recom- 
mended by  many,  is  by  no  means  pos- 
sible in  stout  persons,  while  short-necked 
subjects  also  bear  this  position  badly. 
He  prefers  to  place  a  pillow  well  under 


CHLOROFOKM.    ADMINISTRATION.    ATMOSPHERIC  CONDITIONS. 


73 


the  shoulders,  giving  just  sufficient  ex- 
tension of  the  head  upon  the  trunk  for 
practical  purposes.  This  position  I  have 
found  a  most  advantageous  one  in  opera- 
tions about  the  posterior  nasal  space. 

A  certain  amount  of  care  must  be 
taken  when  the  head  is  not  fully  ex- 
tended, however,  that  the  tongue,  dur- 
ing the  deep  stage,  be  not  allowed  to 
fall  back  against  the  pharynx  and  thus 
tend    to    occlude   the    respiratory   area. 


the  surrounding  air  as  a  cause  of  danger. 
When  the  air  is  surcharged  with  moist- 
ure the  chloroform  condensation  in  the 
pulmonary  air-cells  and  its  subsequent 
entrance  into  the  blood  are  impeded; 
the  stages  of  narcotism  will,  by  this,  be 
prolonged.  Recovery  is  also  slower. 
Syncopal  attacks  in  a  moist  atmosphere 
are  more  likely  to  terminate  fatally. 
Again,  the  moisture  which  should  escape 
from  the  air-passages  cannot  do  so  when 


Position  for  tlie  removal  of  post-nasal  growths.     {Kcinhil  Franks.) 

(UuMln  Jourual  of  Medical  Scionco.  March.  ■«.) 


Howard,  in  1888,  showed  that  the  most 
effectual  way  of  opening  the  air-passages 
was  by  forced  extension  of  the  head  upon 
the  trunk,  tliereby  raising  the  epiglottis 
and  tongue;  but  this  does  not  prove  true 
unless  excessive  extension  be  resorted  to; 
and,  as  this  is  inadvisable,  the  benefit 
of  Howard's  method  is  not  obtained. 

Influence  of  Aiwoxpheric  Conditions. 
— Benjamin  Ward  Eichardson  attached 
much   importance   to   the   condition   of 


the  atmosphere  is  too  saturated,  and  the 
tendency  to  waterlogging  of  the  lungs 
under  chloroform  is  increased. 

The  temperature  also  bears  a  marked 
influence  when  it  is  high,  the  volatiliza- 
tion is  more  rapid,  its  diffusion  and  con- 
densation are  increased,  and  both  the 
onset  and  the  recovery  are  more  rapid. 
The  safest  temperature  is  60°  to  70°  F.; 
a  higher  rather  than  a  low  range  is 
best. 


74 


CHLOROFORM.    ADMINISTRATION.    PREPARATION  OF  THE  PATIENT. 


Chloroform  anaesthetization  under 
varying  atmospheric  pressures:  The  ac- 
tion of  chloroform  is  more  rapid  but  less 
lasting  if  the  atmospheric  pressure  is  re- 
duced. The  elimination  of  chloroform 
by  the  lungs  is  much  more  rapidly  ef- 
fected in  animals  subjected  to  very  low 
pressures.  Benedicenti  (Archives  Ital. 
de  Biol.,  vol.  xxiv,  No.  3,  '9S). 

In  India  the  mortality  from  chloro- 
form does  not  exceed  1  in  8000  cases, 
and  in  some  of  the  largest  institutions  it 
is  less  than  1  in  20,000  eases.  Safety  does 
not  appear  to  be  related  to  any  special 
constitutional  condition  of  Indian  races 
and  but  little  to  their  habits.  It  is  prob- 
ably due  entirely  to  the  warm  atmos- 
phere, which  favors  the  rapid  action  of 
the  drug  and  its  rapid  elimination.  To 
obtain  simUar  safety  in  England,  it  would 
be  advisable  to  operate  in  well-ventilated 
rooms,  with  a  temperature  not  below 
70°  F.  Anffisthesia  should  be  produced 
gradually,  with  the  chloroform  diluted 
with  plenty  of  air.  Arthur  Neve  (Brit. 
Med.  Jour.,  Nov.  5,  '98). 

Preparation  of  the  Patient. — The  pa- 
tient should  be  in  an  entirely-loose  gar- 
ment and  in  the  recumbent  position. 
A  quiet,  well-ventilated,  and  well-lighted 
room  should  be  selected. 

Any  foreign  body,  such  as  false  teeth, 
tobacco,  or  any  accumulation  of  mucus, 
should  be  removed  from  the  mouth, 
naso-pharynx,  and  nasal  passages. 

All  solid  food  should  have  been  with- 
held for  at  least  four  hours  and  no  liquid 
food  for  at  least  two  hours  before  the 
administration  of  the  ana3sthetic,  al- 
though a  small  quantity  of  brandy  or 
whisky  may  be  given  a  few  minutes  be- 
fore if  the  patient  be  at  all  debilitated. 

[This  recommendation  is  of  the  great- 
est importance  J  for  the  regurgitation  of 
food  when  the  patient  is  under  the  antes- 
thetie  may,  by  entering  the  larynx,  cause 
asphyxia.     Sajous.] 

The  patient's  fear  should,  as  much 
as  possible,  be  allayed  Ijy  kindly  and  en- 
couraging words,  death  being  sometimes 


caused  by  heart-syncope,  resulting  from 
fright.  A  show  of  surgical  instruments 
should  be  avoided. 

Mental  factors  may  be  influential 
causes  in  the  production  of  chloroform- 
death.  Fear  and  anxiety  may  cause  pro- 
found circulatory  distm-bance,  and  this 
condition  may  predispose  to  danger  when 
an  anesthetic  is  given.  In  such  cases  an 
hypodermic  injection  of  morphine  should 
be  administered,  and  ether  should  be 
employed  instead  of  chloroform  if  there 
is  no  contra-indication.  Robert  Ballard 
(Lancet,  May  7,  '98). 

If  the  operation  is  at  all  to  be  pro- 
longed or  be  of  such  a  nature  as  to  cause 
severe  pain  in  the  waking  state,  an 
hypodermic  injection  of  morphine,  V4 
grain,  should  be  administered  twenty 
minutes  before  the  chloroform  is  given. 

Administration  and  Dose. — As  in  the 
case  of  other  agents,  it  is  obvious  that 
the  purest  chloroform  obtainable  should 
be  employed.  Many  instruments  were 
devised  for  the  purpose  of  administering 
auEEsthetics  in  general  (the  principal  ones 
will  be  described  under  Ether),  but 
these  are  seldom  employed  outside  of 
hospitals.  Except  under  certain  condi- 
tions, when  the  anaesthetic  is  admin- 
istered in  the  presence  of  gaslight,  the 
simplest  way  to  apply  chloroform  is  on 
a  towel  or  handkerchief;  or  a  cone  or 
funnel  may  be  made  with  a  folded  towel 
into  which  the  anaesthetic  may  conven- 
iently be  dropped. 

On  account  of  its  irritant  action,  chlo- 
roform should  not  be  allowed  to  come 
into  contact  with  the  eyes  or  face.  In 
the  case  of  a  fair-skinned  female  patient, 
it  is  advisable  to  apply  vasclin  or  cold 
cream  where  the  chloroform-vapor  is 
likely  to  touch  the  skin. 

A  drop-bottle  should  be  employed  for 
tlie  ana'sthc'tic,  tlie  pouring-out  method 
usually  employed  licing  a  dangeroii.-i 
procedure. 


CHLOROFOKM.     ADIIINISTRATIOX  AND  DOSE. 


75 


The  patient  lying  upon  his  back,  his 
chest  is  bared,  a  compress  placed  over 
his  mouth,  and  2,  3,  or  4  drops  of  chlo- 
roform poured  upon  it.  The  compress 
or  cone  is  held  so  as  not  to  close  com- 
pletely the  nostrils  and  mouth,  thus  en- 
abling the  patient  to  inhale  well-diluted 
vapor  at  first.  In  fifteen  seconds  the 
chloroform  will  have  evaporated,  when 
4  or  5  drops  more  are  then  allowed  to 
fall  on  the  centre  of  the  compress,  this 
being  turned  rapidly  so  as  to  avoid  an 
.excessive  intake  of  fresh  air.  This  ma- 
noeuvre is  repeated  about  every  half- 
minute.  When  narcosis  is  complete,  2  or 
3  drops  of  the  anaesthetic  are  used  every 
minute.  Coughing  indicates  that  the  air 
inhaled  is  too  heavily  charged  with  chlo- 
roform, while  struggling  in  the  first 
stage  tends  to  show  that  the  patient  is 
feeling  the  want  of  air — a  terror-inspir- 
ing sensation. 

The  extreme  danger  of  rapid  chlo- 
roformization  was  repeatedly  emphasized 
by  Richardson,  who  argued  that  fatal  re- 
sults follow  upon  the  sudden  impact  of 
chloroform — an  irritant  vapor  —  upon 
the  nervous  periphery  of  the  breathing- 
surfaces.  (See  influences  upon  the  nasal 
mucous  membrane,  infra.)  Tliis  sudden 
impact  causes,  in  his  opinion,  a  contrac- 
tion of  the  pulmonary  arterial  vessels; 
thence  results  ischjemia  of  the  lungs  and 
overfilling  of  the  right  heart,  leading  to 
cardiac  stand-still.  A  few  minims  of 
chloroform  injected  into  a  vein  kills  the 
heart-muscle  outright  and  beyond  recov- 
ery. If  the  animal  is  healthy  the  lungs 
prevent  such  a  catastrophe  when  the 
chloroform  is  inhaled;  but  the  author 
contends  that  when  the  heart  is  not 
healthy  the  lethal  dose  may  be  so  small 
that  it  may  pass  through  the  lungs  and 
reach  the  heart,  causing  fatal  syncope. 
Wliile  gradual,  rather  than  rapid,  chlo- 
roformization  (two  minutes  for  infants, 


three  for  children,  and  four  or  five  for 
adults — Snow)  is  recommended,  the  dan- 
ger is  urged  of  overcaution,  as  the  blood 
grows  highly  saturated  with  chloroform 
before  anaesthesia  is  obtained,  and  the 
organs  and  tissues  are  so  saturated  with 
chloroform  that,  should  any  causal  acci- 
dent arise,  it  is  fatal  in  spite  of  all  efforts 
to  withdraw  the  chloroform  from  the 
blood,  since  reabsorption  into  the  blood 
takes  place  from  the  tissues. 

To  settle  this  question  Kionka  con- 
ducted a  series  of  researches  to  deter- 
mine quantity  of  ether  or  chloroform 
necessary  to  produce  narcosis.  He  found 
the  dose  required  to  be  relatively  small. 
Narcosis  was  obtained  when  the  air  con- 
tained from  0.15  to  1.3  per  cent,  of  chlo- 
roform, or  2.1  to  7.9  per  cent,  of  ether. 
The  minimum  quantity  of  ether  neces- 
sary to  produce  anaesthesia  could  be 
greatly  exceeded  without  endangering 
life,  and  narcosis  could  be  prolonged  by 
using  the  same  dose,  while,  under  similar 
conditions,  chloroform  invariably  caused 
death  of  the  animal.  Sleep  under  ether, 
when  once  established,  could  be  main- 
tained with  a  smaller  dose  than  that  re- 
quired to  produce  it.  From  the  begin- 
ning chloroform  caused  early  arrest  of 
heart  and  respiration. 

Eobert  Bell  has  noted  that  the  symp- 
toms of  approaching  danger  under  chlo- 
roform always  appear  in  the  following 
order:  (a)  coughing,  (6)  gasping,  (c) 
choking,  and  (d)  struggling.  If,  at  the 
first  appearance  of  coughing,  the  vapor 
is  given  more  diluted,  no  further  diffi- 
culty will  arise.  On  the  other  hand,  W. 
A.  Parker  ascribed  the  small  number  of 
deaths  observed  in  Scotland  to  tlie  fact 
that  the  anaisthetists  are  not  afraid  of 
chloroform;  they  use  it  fearlessly  in  un- 
stinted doses,  pushing  the  patient  rap- 
idly under. 

Buxton  states  that  there  seems  every 


76 


CXBCLOEOFORM.     UNTOWAKD  EFFECTS. 


reason  to  believe  that  an  overdose  of 
chloroform  may  be  arrived  at  in  one  of 
two  ways:  (1)  a  sudden  intake  of  a  lethal 
dose,  which,  according  to  Sansom,  who 
followed  Snow's  emphatic  teaching,  may 
be  taken  when  even  a  small  quantity  of 
the  anaesthetic  is  thrown  on  lint  or  a 
towel,  or  (2)  through  accumulation  of 
the  drug  in  the  body.  This  commonly 
shows  itself  by  paralyzing  the  medullary 
centres  and  so  producing  cessation  of 
respiration.  Impairment  of  expiration 
is  the  most  usual  cause  of  this,  due  in 
many  cases  to  some  mechanical  cause, 
such  as  emphysema,  falling  back  of  the 
tongue,  sucking  in  of  the  lips,  or  block- 
ing of  the  air-ways  by  mucus  or  blood. 

As  regards  the  lower  mortality  re- 
ported from  Scotland,  Buxton  argues 
that  many  deaths  under  chloroform 
have  occurred  in  that  country;  even  as 
early  as  in  the  days  of  Simpson.  As  no 
public  investigation  is  held  correspond- 
ing with  coroners'  inquests,  as  is  the  case 
in  England,  no  report  gets  into  the  pub- 
lic press.  He  reaches  a  conclusion  sus- 
tained by  experience,  and  verified  by  a 
wide-spread  review  of  the  literature,  to 
the  effect  that  every  individual  requires 
a  specific  dose :  the  drunkard  and  athlete 
require  much ;  the  pale,  frail,  ancemic 
woman  very  little. 

The  stages  of  chloroform  narcotism 
as  given  by  Snow  and  Buxton  are  divided 
into  four: — 

The  first  stage,  from  the  commence- 
ment of  inhalation  to  the  loss  of  con- 
scious control  of  the  limbs. 

The  second,  to  the  stage  of  lo.S8  of  con- 
junctival reflex  and  rigidity  of  the  mus- 
cles. 

The  third,  or  surgical  stage,  when  the 
muscles  are  relaxed  (in  the  main),  the 
corneal  reflex  is  lost,  and  the  pupil  is 
contracted. 

The  fourth  stage,  when  the  medullary 


centjes  are  affected,  the  pupils  dilate,  the 
respiration  gradually  fails,  the  muscles 
are  absolutely  relaxed,  the  sphincters 
cease  to  act,  while  the  circulation  fails. 

Beyond  this  stage  convulsions  occur, 
the  breathing  ceases,  and  the  heart  and 
circulation  come  to  a  stand-still.  The 
complete  relaxation  of  the  muscles  can, 
in  some  cases,  be  arrived  at  only  by  the 
patient's  entering  the  fourth  stage,  and, 
in  the  case  of  chloroform,  such  pushing 
of  the  anaesthetic  can  only  be  accom- 
plished by  seriously  jeoparding  the  pa- 
tient's life.  In  the  case  of  ether,  how- 
ever, a  patient  can,  with  ordinary  care, 
be  allowed  to  pass  into  this  stage  with- 
out danger. 

At  all  times  during  the  administration 
of  the  anaesthetic  the  respiration  and  the 
circulation  should  he  simultaneously 
watched. 

Xlntoward  Effects. — The  chances  that 
no  trouble  will  be  met  with  stand  as  1500 
does  to  1,  provided  average  care  has  been 
taken  in  determining  whether  the  case 
be  not  one  offering  unusual  chances 
against  a  successful  administration.  But 
in  all  cases  certain  allowances  must  be 
made  not  only  for  previously-undiscov- 
ered elements  which  may  suddenly  bear 
their  influence  upon  the  issue,  but  also 
for  known  conditions  which  also  modify 
the  form  of  issue. 

Owen  states  that  there  is  always  risk 
in  giving  chloroform  or  any  other  anaes- 
thetic to  a  child;  but  this  risk  is  dimin- 
ished in  proportion  as  the  vapor  is  ad- 
ministered in  a  careful  manner  and  by 
a  well-instructed  person.  It  is  impor- 
tant to  bear  in  mind,  in  this  connection, 
that  the  general  impression  that  children 
very  rarely  succumb  to  the  influence  of 
chloroform  is  erroneous.  The  many 
deaths  in  children  ranging  from  early  in- 
fancy to  15  years  of  age  have  served  to 
emphasize  this  fact. 


CHLOROFORM.     UXTOWARD  EFFECTS.    SHOCK. 


77 


On  the  other  hand,  the  fear  that  un- 
toward results  will  follow  the  use  of  an 
anaesthetic  in  patients  of  advanced  age 
is  equally  exaggerated,  as  shown  by  a 
large  series  of  cases  reported  in  which  no 
unusual  effect  was  witnessed.  Heath, 
for  instance,  administered  chloroform  to 
a  woman  94  years  old,  to  reduce  a  dis- 
location. The  patient  bore  the  anaes- 
thetic calmly  and  easily.  Indeed,  acute 
suffering  is  a  prolific  source  of  fatal 
shock  in  old  people,  and  antesthesia  thus 
becomes  a  life-saving  agent  in  them. 

As  regards  the  increased  liability  to 
untoward  effects  through  disease,  Key- 
nier  recently  showed  that,  according  to 
the  more  or  less  great  resisting  power  of 
the  various  cells  affected  during  the 
anaesthetization,  are  fatal  accidents  lia- 
ble to  occur.  While  in  alcoholics,  whose 
cerebral  cells  are  in  a  continual  state  of 
hyperesthesia,  delirium  is  observed, 
which  may  reach  the  stage  of  delirium 
tremens;  but  in  these,  also,  heart-wall 
degeneration  is  probable,  and  early  syn- 
cope is  likely  in  proportion.  In  hyster- 
ical subjects  all  varieties  of  hysterical  at- 
tacks may  occur,  even  paralysis  and  syn- 
cope. The  same  is  the  case  in  epileptics. 
In  morphinomaniacs  only  slightly  in- 
toxicated chloroformization  is  easily  and 
rapidly  accomplished;  in  others,  on  the 
contrary,  it  is  more  dangerous.  In 
ataxic  subjects  the  period  of  medullary 
excitement  nearly  always  gives  rise  to 
reflexes  which  may  arrest  the  respiration 
and  heart-movements. 

To  these  morbid  conditions  must  be 
added  those  enumerated  and  involving 
the  circulatory,  respiratory,  and  urinarj' 
systems,  and  prolonged  abdominal  op- 
erations, strangulated  hernia  in  old  and 
exhausted  subjects,  colotomy  and  colec- 
tomy, etc. 

Extra  watchfulness  should  be  observed 
in  all  such  cases,  and  shock  anticipated 


by    preliminary    measures:     stimulants, 
strychnine,  etc. 

Shock.  —  Murray- Aynsley  emphasized 
the  fact  that  many  deaths  under  chloro- 
form occurred  within  a  very  short  time 
after  the  commencement  of  inhalation, 
or  when  comparatively  trifling,  although 
painful,  operations  were  to  be  performed 
(extraction  of  teeth,  etc.)  were  due  to 
slioclc  during  imperfect  ancesthesia.  He 
denies  that  the  experiments  performed 
by  the  second  Hyderabad  Commission 
prove  that  shock  under  chloroform  was 
not  competent  to  produce  syncope,  as 
in  them  painful  operations  were  per- 
formed on  animals  coming  out  of  chlo- 
roform, and  in  a  condition  where,  as  he 
contends,  analgesia  persisted,  although 
anaesthesia  was  imperfect. 

Closely  connected  with  the  production 
of  shock  is  fear,  which  tends  greatly  to 
increase  the  chances  of  cardiac  syncope, 
through  the  exaggerated  functional  ten- 
sion induced.  White  has  shown  that 
even  a  small  amount  of  chloroform  is 
capable  of  inducing  a  fatal  issue  under 
these  circumstances.  There  is  a  marked 
difference  in  this  particular  between 
Europeans  and  Hindoos:  a  fact  which 
has  served  to  markedly  decrease  the  mor- 
tality of  anaesthesia  in  India. 

The  letters  which  are  constantly  ap- 
pearing in  current  medical  journals  in- 
aicate  very  plainly  the  views  which  are 
held  in  this  country  on  the  vexed  sub- 
ject of  chloroform  versus  ether  as  an 
antcsthetic,  but  less  is  generally  known 
of  the  opinions  of  the  profession  in 
America  on  this  matter.  It  might  per- 
haps be  hastily  assumed  that  in  the 
United  St-ates,  the  home  of  antesthesia 
by  ether,  no  other  drug,  and  least  of  all 
chloroform,  would  be  habitually  used. 
To  those  who  are  of  this  opinion  the 
statements  made  by  Dr.  J.  A.  Bodine, 
Adjunct  Professor  of  Surgery  at  the 
New   York   Polyclinic,   will   come   as   :» 


78 


CHLOROFORM.    UNTOWARD  EFFECTS.    SHOCK. 


surprise.  In  a  recent  lecture  he  admits 
freelv  that  chloroform  possesses  many 
advantages  over  ether,  but  points  out 
that  the  administration  of  the  former 
has  been  follo^Yed  by  a  considerably 
larger  proportion  of  deaths  from  the 
anaesthetic  than  when  the  latter  was 
employed.  He  thinks,  however,  that  this 
unfortunate  fatality  might  be  offset  to 
some  extent  by  the  deaths  which  take 
place  some  time  afterward,  from  kidney 
irritation  and  lung  involvement  after 
ether. 

He  contends  that  most  chloroform 
deaths  are  due  to  vasomotor  paralysis, 
and  that  deaths  from  fright  occur  just 
in  the  same  way.  Two  instructive  and 
suggestive  cases  are  cited.  In  the  first, 
the  patient,  a  very  nervous  individual, 
became  so  frightened  before  the  opera- 
tion that  the  rhythm  of  his  breathing 
was  seriously  disturbed;  the  anaesthetist, 
in  consequence  of  this,  gave  him  some 
preliminary  training  in  deep  breathing 
before  the  administration  of  the  chloro- 
form; the  cone  was  placed  over  his  face, 
and  he  was  told  to  breathe  deeply;  after 
a  few  gasps  he  ceased  to  breathe  and 
could  not  be  resuscitated.  Not  a  single 
drop  of  chloroform  had  been  adminis- 
tered. In  the  second  case,  the  patient, 
who  was  also  a  very  nervous  man  and 
very  fearful  of  the  result  of  the  opera- 
tion (for  hsemorrhoids),  was  given  an 
enema  before  any  anaesthetic  was  ad- 
ministered; he  thought  this  was  the 
first  step  of  the  operation,  ceased 
breathing,  and  died.  In  both  these  cases 
the  necropsy  revealed  no  morbid  state 
except  the  tense  abdominal  veins,  in 
wliich  nearly  all  the  blood  of  the  body 
had  collected  as  a  result  of  the  vaso- 
motor paralysis  consequent  upon  the 
fright. 

Dr.  Bodine,  therefore,  concludes  that 
fright  may  be  an  element  in  the  pro- 
duction of  death  in  cases  in  which 
chloroform  is  used.  He  states  that  seven 
out  of  every  ten  deaths  reported  from 
chloroform  anajsthesia  occur  during  the 
preliminary  stage,  when  only  a  few  drops 
up  to  a.  drachm  have  been  given.  There 
is  nc;;ativc  evidence  also  in  the  fact  that 
in  obstetrical  practice  chloroform  is  the 
ana'sthctic  of  choice;    this  is  due  to  al- 


most complete  absence  of  a  chloroform 
mortality  during  labor.  As  an  explana- 
tion of  this  freedom  from  danger  we 
have  the  circumstance  that  women  are 
not  fearful  about  the  anaesthetic  in  their 
confinements,  but  ask  freely  for  it. 
Children,  also,  are  not  frightened  as 
adults  are,  and  consequently  sufl'er  little 
from  chloroform  as  an  anresthetic.  Dr. 
Bodine  refers,  in  addition,  to  the  inter- 
esting fact  that  the  negro  of  the  South- 
ern States  stands  chloroform  very  well; 
he  has  a  child-like  faith  in  lus  physician 
and  does  not  fear  anj'  of  the  measures 
that  he  may  adopt.  Yet  the  negro  may 
die  from  fright,  as  a  graphic  story  of 
a  student  trick  told  by  the  writer 
proves. 

The  conclusion  is,  therefore,  reached 
that  we  must,  for  the  safe  administra- 
tion of  chloroform,  eliminate  fright.  Dr. 
Bodine  tells  his  patient  to  put  his  hands 
tightly  together,  the  fingers  interlacing, 
and  to  grip  them  firmly;  he  asks  him 
to  fix  his  mind  upon  that  action,  to 
listen  to  the  voice  of  the  anaesthetist 
and  to  do  what  he  tells  him,  and  to 
breathe  deeply  and  quietly  and  not  to 
mind  the  sensations  which  come  over 
him.  General  conversation  in  the  neigh- 
borhood of  the  patient  should  not  be 
allowed.  The  writer,  in  conclusion,  thinks 
that  if  deaths  from  fright  could  be  elimi- 
nated, chloroform  would  be  a  much  safer 
anaesthetic  than  ether,  and  says:  "If  I 
had  to  choose  an  anaesthetic  for  myself 
to-morrow,  I  should  take  chloroform, 
but  I  should  want  it  administered  by  a 
careful  expert  anaesthetist." 

These  views,  although  jjcrliaps  opti- 
mistic, are  well  worthy  of  being  kept  in 
mind  by  the  profession  on  this  side  of 
the  Atlantic.  Editorial  (Brit.  Med.  Jour., 
Feb.  21,  1903). 

Too  prolonged  a  fast  prior  to  taking; 
chloroform  is  considered  dangerous  by 
Murray-Aynsley.  Christopher  Heath, 
when  an  operation  is  likely  to  be  very 
prolonged,  administers  an  enema  of  hot 
beef-tea,  half  an  hour  before  the  admin- 
istration. Silk  hafl  recommended  the 
"hospital  regimen"  for  some  days  before 
the  operation. 


CIlLOKOl-'OKll.     UNTOWARD  EFFECTS.     STRUGGLING. 


79 


Stimulants  were  advocated  even  by  B. 
VV.  Eichardson,  who  gave  alcohol  in 
definite  doses,  twenty  minutes  before  the 
inhalation. 

Formula: — 

IJ  Tinct.  chloroformi,  1  drachm. 
Spir.  tenuior,  1  ounce. 

This  was  given  in  water  and  sweetened 
if  preferred. 

Foxwell  also  gave  alcohol  when  the 
heart  was  not  orderly  and  calm  five  min- 
utes before  beginning  the  administra- 
tion of  the  anassthetic,  but  opium,  given 
two  or  three  hours  before,  he  considered 
even  better. 

Too  little  importance  is  usually  at- 
tached to  struggling,  which,  according 
to  Lawrie,  is  produced  (1)  by  fright, 
leading  to  purposeful  resistance;  (2)  by 
choking  or  asphyxia  from  overconcen- 
tration  of  the  vapor,  owing,  generally,  to 
the  cap  being  held  too  close  to  the  face 
at  first  or  afterward  when  the  chloro- 
form is  being  renewed;  and  (3)  by  in- 
toxication,— i.e.,  the  so-called  "strug- 
gling stage."  Dudley  Buxton  considers 
the  struggling  of  intoxication  as  ex- 
tremely dangerous.  The  breathing  is 
then  irregular  and  the  amount  of  chloro- 
form in  the  circulation  is  considerable, 
anaesthesia  being  nearly  complete:  fac- 
tors markedly  increasing  the  chances  of 
cardiac  syncope  and  general  toxjemia. 

The  inhaler  should  be  removed  from 
the  face  for  a  few  respirations,  which 
does  not  necessarily  cause  a  break  in  the 
narcosis,  as  chloroform  still  remains  in 
the  air-cells;  and,  as  soon  as  respiration 
has  resumed  its  normal  character,  the 
chloroform  is  reapplied. 

Certain  regions  are  especially  prone  to 
encourage  cardiac  syncope  when  sub- 
mitted to  rough  handling  in  surgical  pro- 
cedures. Traction  upon  the  omentum 
and  undue  manipulation  of  the  intestines 


and  other  viscera  are  probably  the  most 
active  factors  of  this  kind.  Operations 
upon  the  anus  have  also  shown  a  tend- 
ency in  this  direction.  Operations  that 
would  be  attended  by  great  pain  without 
an  anesthetic  seem  to  show  the  greatest 
tendency  to  produce  cardiac  failure. 

The  part  played  by  reflex  action  in  the 
production  of  syncope  has  not  as  yet  re- 
ceived much  attention.  Laborde,  some 
years  ago  (1890),  observed  that  the  heart 
of  the  monkey  was  immediately  arrested 
by  the  irritative  action  of  chloroform- 
vapor  on  the  nasal  distribution  of  the 
trigeminus,  and  observed  that  the  ap- 
plication of  a  solution  of  cocaine  to  the 
nasal  mucous  surfaces  prevented  the 
untoward  result.  Recently  Eosenberg, 
Guttmann,  and  others  have  utilized  this 
prophylactic  measure  during  surgical 
anffisthesia,  and  have  lauded  its  merits. 

The  vapors  of  this  drug  are  able,  by 
their  irritating  action  upon  the  nervous 
elements  within  the  naso-pharyngeal 
mucous  membrane,  to  determine  a 
brusque  arrest  of  the  heart  and  respira- 
tion. This  paralysis  occurs,  moreover, 
very  easily  if  the  subject  be  put  under 
chloroform  during  a  state  of  very  great 
excitement.  In  order  to  prevent  as  far 
as  possible  this  cause  of  death,  which  is 
always  imminent,  as  soon  as  one  ap- 
proaches the  nose  of  a  sick  person  with 
a  compress  soaked  with  chloroform  it  is 
necessary  to  decrease  the  unnecessary 
excitement  of  the  patient  and  the  sus- 
ceptibility of  the  terminal  expansion  of 
the  fifth  cranial  nerves.  The  best  means, 
according  to  the  author,  of  accomplish- 
ing this  purpose  consists  in  giving  a  pre- 
ventive injection  consisting  of  hydrate 
of  morphine.  0.10  gramme;  sulphate  of 
atropine.  0.01  gramme;  sulphate  of 
sparteine.  1.00  gramme;  distilled  water, 
10  grammes,  to  every  individual  to  be 
chloroformed.  Irrigation  of  the  nasal 
mucous  membrane  and  of  the  pharynx 
and  glottis  with  a  concentrated  solution 
of  cocaine  is  also  of  great  benefit  in  sup- 
pressing the  susceptibility  of  these  re- 


80 


CHLOROFOKM.    SYMPTOMS  OF  COLLAPSE. 


gions.  It  is  also  necessary  to  have  care 
to  keep  the  tongue  forwara  in  the  mouth 
•with  special  forceps  during  the  entire 
duration  of  the  chloroformization,  thus 
avoiding  a  sliding  of  this  organ  back- 
ward over  the  orifice  of  the  glottis, 
thereby  provoking  asphyxia,  and  being 
ready  to  carry  out  rhythmical  traction 
on  this  organ  in  case  unfavorable  symp- 
toms arise.  Laborde  (Medical  News, 
July  5,  1902). 

One  hundred  and  twenty  experiments 
to  ascertain  the  part  played  by  vagus 
inhibition  in  chloroform  poisoning.  In 
54  cases  vagus  inhibition  embarrassed 
the  circulation  to  a  more  or  less  dan- 
gerous extent,  and  in  33  experiments 
was  the  immediate  cause  of  death.  To 
sum  up:  1.  A  heart  which  has  been 
poisoned  by  inhalations  of  chloroform 
of  a  strength  of  2  per  cent,  and  upward 
can  always  be  permanently  inhibited  by 
stimulation  of  the  vagi  with  the  faradic 
current  when  the  blood-pressure  has 
fallen  to  about  40  to  50  millimetres  of 
mercury  pressure.  2.  Chloroform  raises 
the  excitability  of  the  vagus  mechanism, 
particularly  in  the  early  part  of  the  ad- 
ministration. 3.  The  increased  excita- 
bility of  the  vagus  mechanism  is  due  to 
the  action  of  chloroform  on  the  vagus- 
centres,  and  the  inhibitory  action  is 
more  intense  from  being  exercised  upon 
a  heart  whose  spontaneous  excitability 
is  diminished  by  the  action  of  the  chloro- 
form upon  it.  4.  Chloroform  adminis- 
tered to  morphinized  dogs  in  air  contain- 
ing not  more  than  1.5  per  cent,  of  the 
vapor,  after  a  period  of  mild  excitation 
slowly  depresses  vagus  excitability.  The 
excitability  may  again  be  raised  with 
more  or  less  readiness  according  to  the 
duration  of  the  administration  and  tlie 
endurance  of  the  vagi  by  increasing  the 
pcrccntiige  strength  of  the  chloroform 
or  by  asphyxia.  5.  Vagus  inliibition  is, 
in  dogs,  the  great  factor  in  the  causa- 
tion of  sudden  death  from  chloroform. 
0.  DangcroiiH  inhibition  is  liable  to  occur 
whenever  the  strength  of  chloroform  in 
the  air  inhaled  rises  above  2  per  cent. 
E.  H.  Embley  (Hrit.  Med.  .Tour.,  April 
12,  1902). 
Raul  has  tracer]  chloroform  deaths  to 
reflex  paralysis  of  the  tongue  and  neigh- 


boring parts,  while  Yallas  considers  pri- 
mary syncope,  due  to  laryngeal  reflex, 
as  one  of  the  usual  modes  of  death  when 
chloroform  is  employed. 

We  have,  in  the  production  of  asthma 
through  intranasal  pressure,  distinct  col- 
lateral evidence  of  the  nervous  relation- 
ship existing  between  the  upper  and 
lower  respiratory  tract,  and,  in  the  re- 
current branch  of  the  pneumogastric,  an 
evident  indirect  association  between  the 
larynx  and  {he  heart,  to  say  nothing  of 
the  sympathetic  system,  which  plays  the 
most  important  role  in  all  reflex  mani- 
festations. 

Symptoms  of  Collapse, — According  to 
Guthrie,  the  symptoms  are  alike  in  all 
cases,  and  are  as  follow:  Sudden  and 
complete  blanching  of  the  face  takes 
place,  leaving  it  of  a  ghastly-gray  hue. 
The  term  "pallor"  conveys  no  idea  of 
the  actual  appearance.  The  eyelids  fall 
open,  the  eyeballs  are  fixed  in  the  up- 
ward position,  with  pupils  fully  dilated 
as  under  extreme  atropinism.  At  the 
same  time  the  cornea  becomes  glazed 
and  sticky,  giving  an  appearance  which, 
once  seen,  is  never  forgotten.  It  can 
only  be  described  in  a  somewhat  fanciful 
manner  by  saying  that  the  light  seems 
to  fade  from  the  eye  as  does  the  color 
from  the  cheek  and  lips.  Probably  it  is 
due  to  flaccidity  of  the  cornea  from  de- 
crease of  intra-ocular  tension,  noticed  by 
Dubois  (See.  de  Biologic,  '84).  It  is 
the  undoubted  look  of  death. 

The  appearance  of  a  person  in  a  dead 
faint,  or  just  after  a  severe  accident,  is 
no  more  than  the  shade  of  that  which 
obtains  in  cases  of  chloroform  collapse. 

The  pulse  and  cardiac  impulse  are  at 
these  times  no  lonfjer  to  he  felt.  Respira- 
tion commonly  ceases  at  the  moment  when 
the  llanching  and  stoppage  of  the  pulse 
occur,  but  at  times  a  few  feeble  and 
irregular    inspiratory   gasps   are   subse- 


CHLOROFORM.    SYMPTOMS  OF  COLLAPSE. 


81 


quently  drawn.  The  patient  is,  to  all 
appearances,  dead.  Whether  the  heart 
actually  ceases  to  beat  at  such  times  will 
probably  never  be  ascertained,  for  the 
moments  are  too  valuable  to  be  spent  in 
delicate  investigations  on  this  point. 
Neither  is  it  possible  to  affirm  from  clin- 
ical observation  that  the  heart  becomes 
dilated,  as  in  the  experiments  of  Mac- 
AVilliam  and  Johnson  on  animals.  Time 
cannot  be  wasted  in  mapping  out  the 
area  of  the  heart's  dullness  in  a  patient 
who  is  in  imminent  danger  of  death. 

In  some  cases  lividity,  accompanied 
by  turgescence  of  the  veins  of  neck  and 
face,  immediately  precedes  the  blanch- 
ing and  look  of  death,  and  is  coincident 
with  the  stoppage  of  respiration.  Pos- 
sibly dilatation  of  the  heart  has  actually 
taken  place,  and  the  condition  is  that  of 
the  true  cardiac  syncope  described  by 
Snow. 

It  might  be  objected  that,  were  dilata- 
tion present,  the  cyanosis  should  con- 
tinue, and  not  give  place  to  pallor;  but, 
possibly,  as  the  heart  fails  regurgitation 
takes  place  into  the  inferior  cava,  and 
allows  the  blood  from  the  distended 
veins  of  neck  and  head  to  enter  the  right 
heart. 

In  children,  cyanosis,  except  where 
actual  mechanical  asphyxia  has  been  pro- 
duced, is  less  apparent  than  pallor.  Un- 
der treatment,  children  almost  invariably 
recover  from  these  alarming  conditions, 
whereas  in  adults  the  reverse  is  unfort- 
unately the  case. 

Athetosis  of  the  fingers  is  a  premoni- 
tory sign  of  impending  asphyxia  in 
chloroform  narcosis.  Koblank  (Centralb. 
f.  Gynilk.,  No.  1,  1900). 

As  a  rule,  the  preliminary  signs  of 
collapse  are  sufficiently  well  marked,  and 
if  observed  in  time  many  a  catastrophe 
may  be  averted. 


These  signs  are  circulatory  and  respi- 
ratory. 

The  circulatory  sign  is  the  presence 
of  increasing  pallor,  not  amounting  to 
absolute  blanching. 

Failure  of  respiration  is  marked  by  a 
peculiar  type  of  breathing,  in  which  ex- 
piration is  extremely  short  and  inefficient, 
while  inspiration  is  sudden,  forcible,  and 
gasping,  often  accompanied  by  falling  of 
the  lower  jaw,  and  spasmodic  clonic  con- 
traction of  the  chin-depressers  and  mus- 
cles of  the  neck.  The  inspiratory  gasps 
are  irregular  and  broken,  and  occur  with 
increasing  slowness  until  the  condition 
of  sudden  collapse  ensues. 

This  type  of  breathing  is  precisely 
similar  to  that  which  is  often  seen  in  a 
patient  dying  of  respiratory  failure  from 
other  causes. 

Under  the  influence  of  chloroform  the 
pupil  first  dilates  and  then  contracts. 
The  dilatation  of  the  pupil  of  incomplete 
chloroform  narcosis  is  due,  according  to 
Arthur  Ward,  to  mental,  sensory,  or 
sympathetic  impulses  aflecting  the  semi- 
narcotized  cerebrum,  and  so  giving  rise 
to  reflex  inhibition  of  the  centre  of  the 
third  nerve.  The  activity  is,  therefore, 
due  to  the  fact  that  the  centre  itself  is 
not  narcotized.  In  complete  narcosis 
the  contracted  pupil  is  due  to  the  com- 
plete subjection  of  the  cerebrum,  while 
the  unopposed  third-nerve  centre  re- 
mains active,  all  cerebral  reflexes  being 
now  barred.  I7i  dangerous  narcosis  the 
third-nerve  centre  itself  becoming  poisoned, 
its  action  no  longer  controls  the  pupil, 
which  dilates  and  grows  less  and  less 
sensitive  to  light,  while  the  globe  becomes 
fixed.  This  fixation  of  the  eyeball,  to- 
gether with  the  stertor  of  breathing  and 
the  sluggish  pupils,  forms  the  contrast 
between  the  danger-stage  of  chloroform 
sleep  and  the  second  stage,  when  dilata- 


82 


CHLOROFORM.    METHODS  OF  RESUSCITATION. 


tion  of  the  pupil  is  associated  with 
shallow  breathing,  etl'orts  at  vomiting, 
pupils  reacting  to  light,  and  return  of 
conjunctival  and  other  reflexes.  The 
period  of  going  under  is,  Ward  thinks, 
the  one  of  most  danger.  The  patient 
then,  by  holding  his  breath,  debilitates 
the  respiratory  centre  by  cutting  off  its 
oxygen-supply,  and  so  predisposes  it  to 
injur}'  by  any  access  of  strength  of  the 
chloroform-vapor. 

Any  material  dilatation  of  the  pupils 
means  either  that  the  patient  is  coming 
around — pupil  active  and  other  reflexes 
will  follow — or  that  the  patient  is  getting 
too  far  under, — stertorous  breathing, 
sluggish  pupil,  fixed  eyeballs.  In  first 
case  more  chloroform;  in  second,  drug 
to  be  withheld  till  contraction  recurs.  A. 
H.  \Yard  (Cleveland  Med.  Gaz.,  Sept., 
'95). 

The  degree  of  narcotism  present  may, 
to  a  great  degree,  be  determined  by  pu- 
pils. Breathing,  pupil,  and  pulse  must 
be  watched.  White  (Brit.  Med.  Jour., 
Apr.  20,  '95). 

When  breathing  assumes  automatic 
character,  indicating  that  patient  is  un- 
conscious, the  amount  of  chloroform 
should  be  regulated  by  the  size  of  the 
pupil;  pin-point  pupil  is  the  safest  sign; 
large  pupil  may  mean  narcosis.  R.  Gill 
(Jour.  Amer.  Med.  Assoc,  June  8,  '95). 
The  pupil  becomes  smaller  as  the  pa- 
tient goes  under  the  influence  of  the 
drug,  and  just  enough  chloroform  should 
be  given  to  keep  the  pupil  a  moderate 
size.  Although  the  moderately  con- 
tracted pupil  reacts  when  one  eye  is 
opened,  yet,  when  both  eyes  are  opened, 
the  pupils  suddenly  become  contracted. 
This  is  tlic  limit  of  the  pupillary  reac- 
tion to  liglit  in  chloroform  narcosis.  A 
few  more  drops  may  then  be  added 
slowly;  but,  if  he  is  almost  awake,  they 
must  be  dropped  on  rapidly.  Adolf 
Flockemann  (Ct-nlralb.  f.  C'liir.,  May  25, 
1901). 
Methods  of  Resuscitation.  —  When 
there  are  indications  of  syncope,  no  time 
should  be  lost  in  ascertaining  the  degree 
of  danger  present  and  the  most  active 


means,  artificial  respiration  by  Syl- 
vester's method  or  inversion,  while  an 
assistant  is  giving  hypodermic  injection 
oi"  '/so  grain  of  strychnine,  should  at 
once  be  resorted  to. 

Whether  artificial  respiration  will  or 
will  not  succeed  depends,  according  to 
B.  W.  Eichardson,  upon  several  circum- 
stances: (1)  the  time  which  has  elapsed 
since  apparent  cessation  of  vital  action 
in  the  lower  animals,  even  after  seven 
minutes'  restoration  has  occurred;  (3) 
a  high  temperature,  which  favors  clot- 
ting in  the  pulmonary  circulation;  (3) 
extreme  cold;  (4)  rough  movement;  (5) 
inexpert  artificial  respiration  may  give 
the  coup  de  grace  to  the  enfeebled  heart. 

The  defects  usually  witnessed  consist 
in  too-rapid  motions,  and  incomplete 
emptying  of  the  kings,  so  as  to  induce 
rapid  elimination  of  the  chloroform. 

Murray-Aynsley  lays  stress  upon  the 
fact  that  artificial  respiration  should  not 
be  begun  by  an  act  of  inspiration;  that 
is,  by  dragging  the  arms  above  the  head, 
for  such  a  proceeding  sei-ves  to  promote 
further  absorption  into  the  blood  of  the 
chloroform  from  the  saturated  air  in  the 
lungs.  They  should  first  be  brought 
down  close  to  the  body;  the  thorax  is 
then  compressed  and  the  arms  are  only 
elevated  when  the  chloroform-laden  air 
is  as  much  as  possible  forced  out.  Care 
should  be  taken  to  clear  thoroughly  the 
mouth  and  throat  of  saliva,  mucus,  vom- 
ited matter,  blood,  etc.,  that  may  be 
present. 

Wood  considers  "forced  respiration" 
the  most  valuable  plan.  He  employs  a 
pair  of  bellows  which  are  connected  with 
a  tracheal  tube  by  India-rubber  tubing; 
a  face-mask  is  also  required. 

Cases  in  which,  all  the  usual  resusei- 
tative  mciisures  having  failed,  complete 
inversion  and  suspension  by  the  bent 
knees  over  the  operator's  shoulders  re- 


CHLOROFORM.    METHODS  OF  RESUSCITATION. 


83 


suited  in  recovery.     Prince   (Ther.  Gaz., 
Jan.,  '93). 

Rapid  and  violent  artificial  respiration 
and  overvigorous  efforts  in  the  direction 
of  inversion,  etc.,  may,  if  the  heart  is 
already  deeply  clilorofornied,  lead  to  a 
fatal  distension  of  that  organ.  Leonard 
Hill  and  Barnard  (Brit.  Med.  Jour.,  Nov. 
20,  '97). 

Complete  inversion — i.e.,  suspending 
the  patient  by  the  feet  or  bent  knees — 
is  sometimes  rapidly  effective.  Dudley 
Buxton  regards  Nekton's  inversion 
method  as  the  best  procedure  in  cardiac 
failure  when  no  pulmonary  or  venous 
engorgement.  In  his  opinion,  artificial 
respiration  stands  facile  princeps  for 
cases  of  failure  of  respiration  when  due 
to  narcotism  of  medullar)'  centres. 

Kelly  recommends  the  following  plan, 
which  combines  inversion  and  artificial 
respiration  in  an  especially-effective 
manner:  "On  the  first  indication  of 
failing  respiration  the  administration 
of  the  anesthetic  should  be  instantly 
suspended  and  the  wound  protected  by 
a  fold  of  gauze.  An  assistant  steps 
upon  the  table  and  takes  one  of  the 
patient's  knees  under  each  arm  and 
thus  raises  the  body  from  the  table  until 
it  rests  upon  the  shoulders.  The  anaes- 
thetizer  in  the  meanwhile  has  brought 
the  head  to  the  edge  of  the  table,  where 
it  hangs  extended  and  slightly  inclined 
forward.  The  patient's  clothing  is  pulled 
down  under  the  armpits,  completely 
baring  the  abdomen  and  chest.  The  op- 
erator, standing  at  the  head,  institutes 
respiratory  movements  as  follows:  In- 
spiration, by  placing  the  open  hands  on 
each  side  of  the  chest  posteriorly  over 
the  lower  ribs,  and  drawing  the  chest 
well  forward  and  outward,  holding  it 
thus  for  about  two  seconds;  expiration, 
reversing  the  movement  by  replacing  the 
hands  on  the  front  of  the  chest  over  the 
lower  ribs  and  pushing  backward  and  in- 


ward, at  the  same  time  compressing  the 
chest.  The  success  of  the  manuiuvre 
should  be  demonstrated  by  the  audible 
rush  of  the  air  in  and  out  of  the  chest." 
The  following  plan  of  resuscitation 
was  pursued  by  Maas,  and,  after  over  an 
hour,  in  each  case  successfully:  The 
mouth  was  opened,  the  tongue  drawn 
forward,  and  the  epiglottis  raised.  The 
precordial  region  was  then  compressed 
thirty  or  forty  times  a  minute  (the  fre- 
quency of  respiration).  A^Tienever  this 
was  stopped,  syncopal  symptoms  again 
appeared.  Subsequently  tracheotomy 
was  performed,  as  it  was  difficult  to  keep 
the  air-passages  free;  but  this  did  not 
assist  the  circulation.  The  respirations 
becoming  almost  imperceptible,  Sylves- 
ter's method  of  artificial  respiration  was 
adopted,  and  more  vigorous  pressure 
made  over  the  breast.  A  similar  course 
was  adopted  in  the  second  case.  The 
manoeuvre  is  thus  performed:  The  op- 
erator stands  upon  the  left  side  of  the 
patient,  and  presses,  with  quick,  strong 
movements,  deep  down  in  the  region  of 
the  heart  with  the  fingers  of  the  right 
hand,  while  the  ball  of  the  thumb  is 
placed  above  the  left  clavicle.  The  num- 
ber of  compressions  is  one  hundred  and 
twenty  or  more  per  minute.  The  left 
hand  should  seize  the  patient  upon  the 
right  side  of  the  thorax. 

Case  in  a  child,  apparently  dead,  in 
which  the  Konig-Maas  method — rapid 
compression  (about  120  per  minute)  of 
the  priEcordium — followed  by  ultimate 
recovery.  Seven  minutes  had  elapsed 
during  which  neither  heart-bent  nor 
respiratory  effort  could  be  detected. 
Leedham  Green  (Birmingham  Med.  Rev., 
Feb.,  '95). 

A  method  recommended  by  Prus  is 
warranted  when  other  means  of  resusci- 
tation have  failed.    This  consists  in  ex- 
j)osing  tlie  pericardium  by  making  an 
I  opening    through    the    chest-walls  —  a 


84 


CHLOROFORM.    METHODS  OF  EESUSCITATION. 


trap-door  flap  of  skin,  muscles,  and  ex- 
eected  ribs — and  grasping  the  heart  and 
pericardium.  The  firmness  of  the  grasp 
is  then  increased  every  second — simu- 
lating its  own  normal  action.  Cases  re- 
cently reported  have  shown  that  the 
heart,  even  in  doomed  subjects,  may  be 
brought  to  react,  at  least  for  a  time. 

For  eases  of  eardiac  failure  the  heart- 
muscle  should  be  grasped  and  compressed 
intermittently  by  pushing  the  hand 
backward  beneath  the  xiphoid  cartilage. 
Hiffe  (Brit.  Med.  Jour.,  Feb.  6,  '92). 

Case  in  a  boy  aged  15  years.  After 
tracheotomy  and  prolonged  attempts  to 
establish  artificial  respiration,  an  open- 
ing was  made  in  the  anterior  wall  of 
the  thorax  on  the  left  side  and  the  peri- 
cardium exposed.  Rhythmical  compres- 
sion of  the  heart  excited  slight  move- 
ments of  this  organ,  and  pulsation  was 
observed  in  the  large  blood-vessels  of 
the  thoracic  cavity,  but  the  respiration, 
in  spite  of  strenuous  and  prolonged 
efforts  to  restore  the  action  of  the 
lungs,  was  not  renewed,  and  after  an 
interval  of  half  an  hour,  during  which 
cardiac  massage  was  energetically  and 
persistently  practiced,  the  movements  of 
the  heart  ceased.  Aglinzeff  (Centralb. 
f.  Chir.,  No.  21,  1901). 

Case  of  chloroform  narcosis  in  a  man 
24  years  old.  Ten  minutes  later  the 
trachea  was  opened  and  air  was  blo-wn 
into  the  lungs,  but  without  result. 
Prus's  cardiac  massage  was  then  decided 
upon.  An  incision  was  made  in  the  skin 
and  muscles  parallel  to  the  third  and 
fifth  ribs  and  left  sternal  edge.  The 
third  and  fourth  ribs  were  cut  close  to 
the  sternum,  and  two  and  a  half  inches 
were  resected  in  the  flap.  In  doing  this 
the  left  pleural  cavity  was  accidentally 
opened.  The  hand  was  then  introduced, 
and  the  heart,  with  the  pericardium  still 
intact,  was  grasped.  No  movements 
were  felt,  but  rhythmical  coinpressionH 
were  syHtematically  practiced,  partly 
by  grasping  the  organ  and  partly  by 
pressing  it  against  the  back  of  the  ster- 
num. After  a  short  time  slight  contrac- 
tions were  felt,  wliifh  gradually  in- 
creased, and  at  the  end  of  one-half  hour    ' 


spontaneous  respirations  were  initiated. 
At   the   end   of   three   hours   breathing 
was    deep    and    without    effort.      Four 
hours   from   the   commencement   of   in- 
halation   respiration     became    ditHcult, 
and  after  a  few  minutes  ceased.     The 
heart  continued   to   beat   from  midday 
until   8   P.M.     The   temperature   of  the 
body     was     fairly    maintained,    falling 
slightly;    after  eight  hours  it  was  98° 
F.      Freyberger     (Hospitalstidende,     B. 
viii,  No.  47;    Treatment,  Jan.  4,  1901). 
Massage  of  the  heart  as  a  means  of 
resuscitation    tried    in    dogs.     The    pro- 
cedure of  massage  of  the  heart  shown 
to  be  both  sound  therapeutics  and  per- 
fectly  justifiable  in   all   cases   of  death 
from    cliloroform    or    any    other    ansBS- 
thetic,  as  well  as  from   drowning  and 
allied  conditions,  when  all  other  means 
of     resuscitation     have     failed.     E.     C. 
Kemp     and    A.    W.     Gardner     (Boston 
Med.  and  Surg.  Jour.,  May  21,  1903). 
Strychnine. — The  value  of  strychnine 
as    an    antidote    to    chloroform,    when 
given  hypodermically,  is  insisted  upon 
by  many,  and  the  experience  of  the  past 
few  years  seems  to  corroborate  this  opin- 
ion.   Its  main  object  is  to  sustain  vitality 
until  sufficient  elimination  of  the  ansES- 
thetic  has  taken  place.    It  must  be  used 
energetically    and    administered    hypo- 
dermically. 

The  use  of  the  electrical  current  in  act- 
ing upon  the  respiratory  centres  at  once, 
and  by  increasing  the  current  rapidly, 
keeps  the  respiratory  mechanism  during 
tlie  dormant  stage  of  strychnine  after 
injection.     S.  T.  Reid  (Brit.  Med.  Jour., 
Nov.  20,  '97). 
Hydrocyanic  Acid.  —  This  agent  has 
been  suggested  by  Hobday  recently,  but 
its  use  is  not  to  be  recommended  until 
its  merits  will  have  been  demonstrated. 
Electricily.  —  According    to     II.     C. 
Wood,  attempts  to  excite  contraction  of 
the  diaphragm  by  electric  stimulation  of 
the    phrenic    nerve    are    fraught    with 
danger,  the  overflow  of  the  current  being 
likely    to    lead    to    cardiac    inhibition. 
Rockwell,  however,  has  reached  the  con- 


CHLOROFORM.    METHODS  OF  RESUSCITATION. 


85 


elusion  that  the  inhibiting  fibres  going 
to  the  heart  are  less  affected  by  electric- 
ity than  the  accelerator  nerves.  The 
beneficial  efl:ects  of  the  faradic  current 
are  due,  not  to  any  action  it  has  on  the 
heart's  rhythm,  but  to  its  stimulating 
influence  over  respiration. 

The  strength  of  the  current  employed 
to  produce  this  efl:ect  on  respiration  is 
much  less  than  need  be  if  a  cardiac 
stimulation  is  aimed  at,  and  the  appli- 
cation of  one  pole  over  the  pit  of  the 
stomach  and  the  other  under  the  angle 
of  the  lower  maxillary  near  the  anterior 
border  of  the  stemo-mastoid  is  often 
fraught  with  excellent  results. 

Cold. — The  failure  of  respiration  un- 
der an  anaesthetic  may  sometimes  be 
overcome  and  spontaneous  respirations 
initiated  by  pouring  a  quantity  of  ether 
upon  the  bared  abdomen.  The  cold  thus 
produced  will,  says  Hare,  often  prove 
successful  in  restarting  breathing. 

The  well-known  measure  of  slapping 
the  surface  with  wet  towels  is  generally 
utilized,  but  does  not  represent  an  ef- 
fective procedure  in  serious  cases. 

Nitrite  of  Amyl. — Great  reliance  is 
placed,  by  W.  M.  Killen,  on  immediate 
use  of  nitrite  of  amyl,  combined  with 
artificial  respiration.  Marsh  states  that 
it  is  at  the  initial  stage  of  heart-failure 
that  it  is  invaluable.  Dudley  Buxton 
argues  that  whatever  value  nitrite  of 
amyl  may  possess,  it  does  not,  he  thinks, 
act  as  an  antidote  to  chloroform.  He 
has  found  it  most  serviceable  in  failure 
of  the  circulation  from  prolonged  severe 
operations,  in  collapse,  and  fear-syncope. 

Injections  of  Salt  Solution. — The  in- 
jection, either  intravenous  or  hypoder- 
mically,  of  the  physiological  solution  (6 
per  cent.)  of  sodium  chloride  has  been 
advocated  in  chloroform  toxaemia.  The 
quantity  to  be  injected  depends  upon 


the  amount  of  blood  lost  during  the  op- 
eration. 

For  chloroform  toxaemia  the  injection 
either  intravenous  or  hypodermically  of 
the  physiological  solution  of  sodium  chlo- 
ride is  very  highly  recommended.  Bob- 
rofT  (Lancet,  Jan.  9,  '92). 

Infusion  of  salt  solution  in  heart- 
failure  advocated.  Reim  (Centralb.  f. 
Chir.,  Nos.  17,  19,  '95). 
Suprarenal  Capsules. — The  extract  of 
these  organs  has  recently  been  recom- 
mended owing  to  the  powerful  action  of 
this  agent  upon  the  vasomotor  system. 
Conclusions  reached  after  a  series  of 
observations  made  upon  dogs  for  the  pur- 
pose of  testing  the  action  of  the  supra- 
renal extract  upon  these  animals  when 
they  have  been  narcotized  by  chloroform 
almost  to  the  point  of  arrest  of  the  heart 
and  respiration:  1.  The  intravenous  in- 
jection of  the  suprarenal  extract  is  ca- 
pable of  saving  the  lives  of  dogs  suffer- 
ing from  extreme  chloroform  narcosis. 
2.  Compared  with  the  procedures  of  other 
investigators,  notably  those  of  Schiiller, 
Laborde,  and  of  Konig-Maas,  intravenous 
injections  of  the  extract  are  preferable  on 
account  of  its  more  rapid  action.  3.  Ex- 
tract of  suprarenals  exercises  a  marked 
influence  upon  the  respiration,  the  blood- 
pressure,  and  the  tone  of  the  heart- 
muscles  even  in  such  small  amounts  as 
from  15  to  30  grains  of  a  1-per-cent.  solu- 
tion. Hence  it  should  be  borne  in  mind 
that  it  is  a  powerful  remedy  and  should 
not  be  given  in  large  doses.  4.  During 
chloroform  narcosis  it  is  wise  to  have 
prepared  a  fresh  solution  of  suprarenal 
extract,  preferably  sterilized  by  boiling, 
in  order  to  controvert  any  sudden  col- 
lapse. 5.  The  best  results,  in  cases  of  im- 
minent death  due  to  chloroform,  are  ob- 
tained by  means  of  combined  procedures, 
such  as  intravenous  injections  of  supra- 
renal extract,  massage  of  the  cardiac  re- 
gion, and  the  subcutaneous  injection  of 
physiological  salt  solution.  F.  A.  Jlagn- 
kovsky  (Russian  Archives  of  Path. 
Anat.;  Araer.  iledico-Surg.  Bull.,  May 
10,  '98). 

Two  drugs  which  promote  contraction 
of  the  arteries,  and  in  consequence  roust 
antagonize  the  dangerous  fall  of  blood- 


86 


CHLOROFORM.     AFrER-EFFECTS. 


pressure    produced    by    chloroform,    are 
atropine  and  extract  of  suprarenal  cap- 
sule.   Extract  of  suprarenal  capsule  in- 
creases   remarkably    the   rate   and   the 
force  of  the  heart-beat.    Schiifer  (Lancet, 
Feb.  5,  '98). 
Venesection. — This  is  an  old  measure 
which,  nevertheless,  has  merit.    The  es- 
sential point  seems  to  be  that  the  veins 
to  be  opened  should  be  as  large  and  near 
to  the  heart  as  possible,  in  order  that  the 
issuing  stream  of  blood  should  be  of  con- 
siderable volume  and  the  relief  to  the 
heart  as  rapid  and  thorough  as  possible. 
Case  of  arrest  of  the  heart's  action  and 
of  respiration  during  chloroform  anaes- 
thesia in  -which  the  internal  jugular  vein 
was  opened ;    compression  of  the  lower 
chest  to  relieve  the  distended  right  ven- 
tricle then  resorted  to.     Several  ounces 
of  blood  rapidly  escaped,  and,  after  the 
jugular  had  been  clamped  by  two  forceps, 
artificial    respiration   was   resumed.     In 
less  than  half  a  minute  the  patient  made 
a   faint  inspiration,  followed   in  a  few 
seconds  by  another,  and,  artificial  res 
piration   being   continued   energetically, 
the  heart   was   heard  to   beat,  at  first 
slowly;    but  soon  the  pulse  and  respira 
tions  gained  in  strength  and  frequency 
The  operation  was  now  completed  with 
out  further  administration  of  an  anses- 
thetic.      This  case  is  deemed  of  impor 
tance,  as  demonstrating  that  the  bleeding 
from  the  internal  jugular  vein,  by  reliev- 
ing the  distension  of  the  right  heart,  was 
the  main  factor  in  bringing  about  the 
recovery  of  the  patient  from  an  appar- 
ently hopeless  condition.    H.  F.  Water- 
house  (Brit.  Med.  Jour.,  July  18,  '90). 

Bhythmical  Traction  of  the  Tongue. — 
Laborde's  method  has  been  successfully 
employed  in  a  number  of  cases.  Labbe 
employed  it  in  a  case  in  which  flagella- 
tion, artificial  respiration,  and  galvanism 
had  been  tried  in  vain.  Verneuil  extols 
the  method,  especially  when  alternated 
with  fla(.^e]lations  of  the  epigastrium  with 
a  wet  cloth. 

After-effects.  —  Headache,  nausea, 
vomiting,  Ijrnnchial  irritation,  and  hys- 


terical symptoms  frequently  present 
themselves  after  the  use  of  anesthetics, 
but  less  so  after  chloroform  than  after 
ether. 

When  gastric  symptoms — nausea,  vom- 
iting, etc.-— prevail,  milk  and  lime-water 
frequently  succeeds  in  allaying  them. 
If  they  are  stubborn,  lavage  with  a  luke- 
warm solution  of  bicarbonate  of  soda 
will  usually  master  them.  An  hypo- 
dermic injection  of  morphine,  ^/^  grain, 
with  ^/i„o  grain  of  atropine,  may  be  used 
with  confidence  when  the  means  pre- 
viously indicated  fail. 

It  is  a  commonly  observed  fact  that 
vomiting  after  ansesthetization  is  asso- 
ciated with  a  severe  degree  of  circulatory 
depression  and  not  infrequently  with 
actual  sj'ncope.  Editorial  (Lancet,  Nov. 
10,  '94). 

[Several  cases  in  the  year's  literature 
vividly  sustain  this  point.  Ed.,  Annual, 
'96.] 

The  value  of  inhalations  of  vinegar  to 
control  nausea  and  vomiting  after  chloro- 
form is  frequently  extolled.  Accord- 
ing to  Lewin,  the  free  chlorine — one  of 
the  products  of  chloroform  and  which  is 
a  marked  irritant  to  the  pharyngeal 
mucous  membrane  and  induces  vomit- 
ing— is  neutralized  by  the  acetic  acid. 

Of  174  cases  of  vomiting  following  the 
administration  of  chloroform,  125  pa- 
tients were  relieved  by  causing  them  to 
inhale  the  fumes  of  vinegar  previously 
placed  upon  a  towel  and  left  over  the 
face  of  the  patient  for  a  number  of  hours 
after  the  chloroform-mask  had  been  re- 
moved. If  tlie  vomiting  returns  after 
this  treatment  is  stopped  a  renewal  of  it 
will  be  sudicient  to  check  the  relapse. 
Lewin  (La  M6d.  Mod.;  Ther.  Gaz.,  Mar. 
15,  '98). 

Value  of  hyoseine  hydrobromidc  in 
preventing  vomiting  after  chloroform 
antesthcsia  emphasized.  The  elTect  was 
ohscrN'cd  quite  accidentally.  At  tlie 
writcr'H  suggestion  others  have  taken 
it  up,  all  with  the  happiest  results.  Ho 
gives  Vim  grain  hypodcrmioally  as  soon 


CHLOROKOKAl.  THKRAPEUTICS. 


87 


as  tlie  iiiisesthesia  is  discontinued.  It 
should  be  given  at  once,  before  sensa- 
tion returns.  In  the  first  case  in 
which  it  was  used  the  patient  had  been 
repeatedly  anaesthetized,  and  it  had  al- 
ways been  followed  bj'  severe  sickness 
lasting  two  or  three  days.  On  this  oc- 
casion, after  the  hydrobroniide  of  hy- 
oscine  was  given  there  was  no  illness. 
J.  E.  F.  Stewart  (Australasian  Med. 
Gaz.,  Sept.  21,  1903). 

Paralysis  sometimes  ensues.  It  is  usu- 
ally due  to  pressure  against  the  edge  of 
the  table  or  to  strained  position  of  the 
members.  Strychnine  and  electricity 
are  indicated  in  such  cases,  with  mass- 
age calculated  to  increase  the  activity  of 
the  local  circulation. 

Case  of  musculo-spiral  paralysis  from 
pressure.  Patient's  arm  pressed  against 
an  iron  bar.  Several  similar  cases  have 
been  reported.  Commonest  in  laparoto- 
mies where  operator  stands  at  the  side 
and  the  arm  pulled  up  to  be  out  of  his 
way.  Bruns  (Archives  Clin,  de  Bor- 
deaux, Nov.,  '95). 

Paralysis  arises  from  several  causes: 
First,  from  the  position  in  which  the 
patient  is  lying,  whereby  pressure  is  ex- 
ercised upon  a  supplying  nerve,  or  as  a 
result  of  tractions  on  the  arm  or  leg  of 
a  violent  nature.  Second,  the  employ- 
ment of  impure  chloroform,  which  seems 
capable  of  poisoning  the  nervous  system 
and  producing  such  paralysis,  at  the 
same  time  developing  transient  or  per- 
manent albuminuria.  Tasse  (La  Semaine 
Med.,  Mar.  10,  '97). 

Therapeutics. — -The  therapeutic  uses 
of  chloroform  are  somewhat  restricted. 
It  is  an  invaluable  agent,  however,  in 
the  treatment  of  general  convulsions  of 
any  kind  and  of  whatever  origin:  eclamp- 
sia, epilepsy,  etc.  As  a  smaller  quantity 
than  is  necessary  for  surgical  purposes 
suffices,  the  inhalations  are  not  attended 
with  after-effects. 

One  of  the  many  elements  in  the 
toxjemia  of  puerperal  eclampsia  is  the 
changing  of  urea  into  ammonium  car- 
bonate.  This  salt  is  demonstrable  in  the 


faeces  in  eclampsia,  and  it  is  the  result 
01  the  principal  change  in  that  complex 
blood  poisoning  which  by  its  effects  on 
the  nervous  system  give  rise  to  the  con- 
vulsions which  are  so  characteristic.  It 
is  also  well  known  that  chloroform  pro- 
duces a  temporary  glycosuria;  hence  we 
may  readily  assume  that  we  must  have 
glucose  in  the  blood.  If  we  admit  the 
presence  of  this  sugar  in  the  blood,  we 
can  easily  demonstrate  by  our  test-tube 
that  it  does  prevent  the  changing  of 
urea  into  ammonium  carbonate.  Hence 
chloroform,  with  its  accompanying  gly- 
cosuria, is  the  antesthetic  par  excellence 
in  puerperal  convulsions.  Xot  that  i£ 
will  inhibit  the  development  of  all  the 
poisons  in  the  toxaemia,  but  it  will  limit 
the  production  of  the  chief  one.  D.  H. 
Stewart  (Medical  News,  Jan.  3,  1903). 

Whooping-cough. — In  whooping- 
cough  inhalations  of  chloroform  some- 
times act  in  a  remarkable  manner  as  a 
calmative.  Violent  attacks  of  cough  may 
usually  be  stopped  by  pouring  a  few 
drops  on  the  hand  and  holding  the  lat- 
ter a  few  inches  under  the  child's  nose. 
It  is  also  credited  with  value  in  chorea, 
but  the  almost  continuous  abnormal 
movements  in  this  disease  render  its  use 
inadvisable. 

Pahtueition. — The  suffering  of  labor 
may  also  be  greatly  mitigated  without 
danger  by  a  small  quantity  of  chloroform 
inhaled  from  a  cone  just  prior  to  the  on- 
coming pains.  The  labor  is  not  retarded 
and  the  success  of  the  ease  is  not  com- 
promised. The  aim  should  not  be  to 
produce  unconsciousness,  but  to  blunt 
the  sensibility;  given  in  sufficient  dose 
to  produce  surgical  anaesthesia,  the  gen- 
eral relaxation  of  the  uterine  tissues  pro- 
duced tends  to  increase  the  dangers  of 
haemorrhage.  Bedford  Brown,  however, 
states  that  the  alterations  in  the  vaso- 
motor system  of  the  pregnant  woman 
enable  her  to  resist  the  to.xic  action  of 
chloroform  to  a  greater  extent  than 
usual. 


88 


CHLOKOFOKM.    A.  C.  E.  iUXTUEE. 


Eekal  and  Biliaet  Colic. — In  renal 
and  biliary  colic  inhalations  of  chloro- 
form offer  the  best  source  of  relief  when 
the  suffering  is  beyond  the  influence  of 
safe  doses  of  morphine.  It  is  superior 
to  ether  in  that  a  much  smaller  dose  is 
required  to  relieve  the  pain,  while  the 
after-effects  are  comparatively  nil. 

A.  C.  E.  Mixture. 

A.  C.  E.  mixture  is  an  anaesthetic 
proposed  by  Harley  (as  modified  by 
Martindale),  and  composed  of  alcohol, 
as  a  menstruum,  1  part;  chloroform,  2 
parts;  and  ether,  3  parts;  by  bulk.  It  is 
termed  the  "A.  C.  E.  mixture"  from  the 
initial  letters  of  the  names  of  its  ingre- 
dients. It  is  thought  to  present  many 
advantages  over  ether  or  chloroform, 
being  less  dangerous  than  chloroform 
alone  and  more  speedy  in  its  action  than 
ether. 

Administration. — The  A.  C.  E.  mixt- 
ure does  not  seem  to  possess  the  advan- 
tages claimed  for  it  in  text-books.  While 
entailing  the  dangers  of  chloroform  an- 
assthesia,  it  tends  to  cause  confusion  in 
the  recognition  of  the  danger-signals. 

The  fact,  recently  recognized,  that 
chloroform  is  not  as  safe  an  anaesthetic 
for  children  as  was  generally  thought  to 
be  the  case,  has  caused  the  A.  C.  E.  mixt- 
ure to  be  tried  as  a  substitute,  but  only 
for  the  first  stage,  ether  being  then  sub- 
stituted. 

Even  in  very  small  cliildren  it  is  far 
safer  to  commence  the  indiietion  with 
the  A.  C.  E.  mixture  and  substitute  pure 
ether  as  soon  as  that  driif;  can  be  borne. 
Commencing  with  A.  C.  E.  on  an  open 
or  Skinner  inhaler,  the  A.  C.  E.  is  then 
given  in  a  celluloid  mask  of  Rendle's 
pattern,  gi'adually  adding  more  and 
more  ether;  when  a  fair  quantity  of  the 
latter  is  borne,  without  hesitation  the 
sponge  exchanged  for  one  containing 
ether  alone. 

The  following  advantages  claimed:  (1) 
the  time  required  to  produce  good  aniEs- 


thesia  is  rarely  more  than  four  minutes, 
(2)    the  guides  to   the  anoesthetist  are 
clear,    (3)    flaccidity   and  freedom  from 
movement  duiing  the  operation  are  com- 
plete, (4)  the  after-effects  bear  compar- 
ison with  those  after  any  other  method, 
and  (5)  the  method  is  safe.    Even  shoxild 
an  inexperienced  administrator  encoun- 
ter stoppage  of  respiration  from  an  over- 
dose,— the  only  accident  to  be  reckoned 
with, — all  that  is  needed  is  a  little  com- 
pression of  the  chest,  the  circulation  not 
being  prejudicially  affected  as  in  the  case 
of  such  an  event  under  chloroform.    The 
method   is   recommended   especially   for 
children  under  five  or  six  years,  and  for 
any  chUd  with  obstruction  in  the  upper 
air-channels.    In  children  above  that  age 
the  combination  of  gas  and  ether  is  so 
well  borne  that  nothing  need  replace  it. 
G.  Rowell  (Brit.  Med.  Jour.,  May  8,  '97). 
Physiological    Action. — Truman    has 
shown  that  the  depressing  action  of  the 
chloroform  upon  the  heart  by  the  stimu- 
lating action  of  the  ether  is  not  based 
upon  chemical  facts,  the  latter  vaporiz- 
ing out  of  all  proportion  to  the  chloro- 
form.     In     administering     the     mixed 
anesthetics,  therefore,  a  vapor  of  vary- 
ing and   uncertain   composition   is  em- 
ployed. 

The   disproportion   indicated   by   Tru- 
man is   desirable;    the  most  dangerous 
period  is   the   beginning,  and   this   cor- 
responds with  that  of  excess  of  ether. 
Marshall   (London  Lancet,  Feb.  16,  '95). 
TJntoward  Effects. — The  deaths  occur- 
ring  after    tlie   administration    of   the 
A.  C.  E.  mixture  seem  to  be  associated 
with  pathological  conditions  similar  to 
those  met  with  in  fatal  cases  following 
the  use  of  chloroform. 

Death  from  A.  C.  E.  mixture  in  an 
alcoholic  subject  in  whom  three  previous 
administrations  of  the  anresthctic  had 
produced  no  unpleasant  symptoms  ex- 
cepting slight  prolongation  of  the  strug- 
gling stage.  The  physical  examination 
showed  no  lesion  of  the  heart;  the  urine 
contained  no  casts,  albumin,  or  sugar. 
After  a  few  whiffs  and  before  conscious- 
ness was  entirely  lost,  the  patient  strug- 


CHLOROFORM. 


CHLOROSIS. 


89 


gled  violently  and  ceased  breathing.  The 
pulse  continued  to  beat  for  nearly  a 
minute  after  respiration  had  ceased.  No 
post-mortem  permitted.  H.  S.  Jewett 
(N.  Y.  Med.  Record,  Nov.  13,  '97). 

Oxygen  and  chloroform  combined  with 
a  view  of  avoiding  asphyxia.  The  scrik- 
ing  cfTeet  of  this  chloroform-oxygen  nar- 
cosis is  manifested  in  the  following 
symptoms:  After  several  inspirations 
the  skin  and  visible  mucous  membranes 
become  light  red.  Extremely  ansemic 
and  weak  patients  exhibit  a  healthy 
color.  The  pulse  becomes  slower  and 
fuller,  similar  to  a  digitalis  pulse,  and 
its  rate  is  nearly  always  about  60.  Nar- 
cosis has  reached  the  surgical  stage  in 
little  children  in  one-fourth  of  a  minute; 
in  larger  children  and  women,  in  three 
to  seven  minutes;  in  men,  five  to  twelve 
minutes.  An  insufficiency  in  the  chloro- 
form-supply, with  a  consequent  lighten- 
ing of  the  anajsthesia,  increases  the 
pulse-rate.  Respiration  is  absolutely 
uniform,  slow,  and  quiet.  A  stage  of 
excitement  is  but  rarely  observed,  and 
then,  as  in  alcoholics,  it  is  short  and 
moderate  in  degree.  Vomiting,  during 
and  after  antcstliesia  is  comparatively 
rare.  There  is  never  an  increase  of  se- 
cretion of  mucus  and  saliva.  The  sen- 
sations observed  when  the  patient  is 
awakening  are  agreeable  in  character. 

Personal  experience  with  this  form  of 
narcosis  comprises  more  than  three  hun- 
dred cases.  One  hundred  and  sixty-six 
patients  were  fully  conscious  imme- 
diately after  operation;  13  required  be- 
tween 8  and  30  minutes;  one  woman, 
after  the  use  of  55  grammes  of  chloro- 
form, slept  3  hours;  21  dispensary  pa- 
tients got  off  the  table  and  walked 
home.  Kidney  irritation  was  never  ob- 
served. Heinz  Wohlgemuth  (Interstate 
Med.  Jour.,  Oct.,  1901). 

Charles  E.  de  M.  Sajous, 

Philadelphia. 

CHIOROSIS.  —  From    Gr.,    ;^?.wpo5: 

greenish  yellow. 

Definition. — An  affection  of  the  blood 
characterized  mainly  by  a  reduction  of 
the  percentage  of  haemoglobin  and  a 
greenish  hue  of  the  skin. 


By  a  slight  stretch  of  the  imagination 
the  skin  of  a  person  of  dark  complexion 
suffering  from  chlorosis  might  be  called 
greenish  yellow;  but  chlorosis  is  very 
common  in  Sweden,  where  the  inhabi- 
tants are,  as  a  rule,  of  a  very  fair  com- 
plexion; so  that  the  very  name  of  the 
disease  is,  to  a  certain  extent,  a  mis- 
nomer. It  has,  however,  the  sanction  of 
ancient  usages,  and  it  would  be  hard  to 
find  another  to  which  greater  objections 
could  not  be  raised. 

Symptoms. — In  investigating  the  clin- 
ical history  of  a  disease  which  is  practi- 
cally confined  to  the  female  sex  our  first 
inquiries  are  naturally  directed  to  the 
organs  of  reproduction.  We  find  that 
chlorosis  makes  its  appearance  at  or 
about  the  time  of  establishment  of  men- 
struation, and  the  behavior  of  this  func- 
tion in  cases  of  the  disease  in  question 
is  twofold:  It  may  be  either  premature 
or  long  delayed.  Niemeyer  states  that 
he  has  never  known  the  menses  to  ap- 
pear between  twelve  and  thirteen  years 
of  age  in  a  girl  with  undeveloped  breasts 
without  the  supervention  of  chlorosis. 
A  premature  appearance  of  the  menses 
is,  therefore,  one  of  the  important  events 
in  the  clinical  history  of  chlorosis.  In 
such  cases,  menstruation  may  appear  but 
once,  the  discharge  being  followed  by 
amenorrhoea  and  chlorosis.  In  the  other 
class  of  cases  the  menses  do  not  appear 
at  the  usual  time;  the  breasts  and  uterus 
remain  undeveloped,  while,  at  the  same 
time,  a  decided  degree  of  chlorosis  makes 
its  appearance.  The  exact  relation  be- 
tween the  amenorrhoea  and  tlie  blood- 
change  is  not  understood,  although  it  is 
probable  that,  in  cases  of  amenorrhoea 
with  a  properly-developed  genital  sys- 
tem, the  suppression  of  menstruation  is 
secondary  to  the  blood-change,  whereas 
in  those  cases  with  an  undeveloped  state 
of  the  uterus  and  its  appendages  the  re- 


90 


CHLOROSIS.    SYMPTOMS. 


lation  is  not  so  clear.  The  other  symp- 
toms of  chlorosis  are  secondary  to  the 
blood-change  and  include  the  yarions 
manifestations  of  anaemia  in  general. 

Analysis  of  232  cases,  showing  that  im- 
perfect evolution  of  menstruation,  as  evi- 
denced by  scantiness  of  the  flow  and  ir- 
regularity of  the  periods,  is  as  regular  a 
feature  of  chlorosis  as  the  imperfect  evo- 
lution of  the  red  corpuscles  of  the  blood. 
These  constants  were  not  related  to  each 
other  as  cause  and  effect,  but  were  inde- 
pendent one  of  the  other.  At  the  same 
time  there  is  a  close  relationship  between 
them,  whereby  the  reproduction  and  de- 
velopment of  the  red  corpuscles  of  the 
blood  are  governed  by,  or  formed  part 
of,  the  menstrual  cycle;  and  both  are 
influenced  by  a  greater  rhythmic  action 
which  determined  the  time  and  activity 
of  development,  growth,  and  reproduc- 
tion. W.  Stephenson  (Brit.  Med.  Jour., 
Mar.  16,  '89). 

It  is  in  this  disease  that  the  inorganic 
cardiac  murmurs  are  so  frequently  heard, 
especially  over  the  base  of  the  heart,  i.e., 
over  the  points  of  the  origin  of  the 
aorta  and  pulmonary  artery. 

In  205  cases,  115  had  cardiac  bruits. 
Of  these,  56  were  audible  at  the  base,  13 
at  the  apex,  24  at  base  and  ape.x,  and  22 
at  base,  apex,  and  back.  The  last  group 
were  always  accompanied  by  distinct 
dilatation  of  the  ventricle  and  strong  im- 
pulse ;  they  were  the  first  to  disappear 
under  treatment:  a  fact  which  shows 
that  they  are  present  in  the  more  ad- 
vanced eases.  In  2  of  the  22  cases  the 
murmur  persisted  after  seven  and  nine 
months,  respectively.  These  remain  as 
permanent  mitral  regurgitations.  Barr 
(Amcr.  Jour.  Med.  Sciences,  Oct.,  '91). 

Many  of  the  bruits  supposed  to  be  in- 
tracardiac really  due  to  the  action  of  the 
heart  against  the  lungs.  Potain  (L'Union 
Mf-d.,  Dec.  23,  30,  '00). 

The  bruit  <le  diahle  and  venous  hums 
in  cliloroHiH.  The  former  occurred  in  51.4 
per  cent,  of  personal  cascB:  a  proportion 
which  is  low,  inasmuch  as  the  hoemo- 
globinometer,  wliich  detccls  the  diHoase 
in  the  absence  of  pallor  and  other  visible 
HignH,   was   used.       Ah   to   venous    liuins, 


none  found  in  49.4  per  cent,  of  ISO  eases ; 
on  the  right  side  only  in  33.3;  on  the 
left  side  in  6.1,  and  on  both  sides  in  11.1 
per  cent.  Of  27  cases  in  which  relapses 
occurred,  66  per  cent,  have  venous  hums: 
a  fact  which  may  prove  of  some  use  in 
prognosis.  The  bruits  usually  disap- 
peared when  the  haemoglobin  showed 
some  increase.  Richardson  {Lancet,  June 
27,  '91). 

Venous  hums  disappear  after  bleeding 
cases  of  chlorosis;  hence  the  cause  of 
these  is  a  plethora,  due  to  hypoplastic 
blood-vessels.  Schubert  (Wiener  med. 
Woch.,  May  2,  '01). 

Careful  examination  of  the  heart  in 
22  eases  of  chlorosis  gives  the  following 
conclusions:  In  22  cases  of  chlorosis,  in 
which  no  other  cause  for  an  alteration  of 
the  heart  was  present,  20  showed  an  en- 
largement of  the  relative  heart-dullness, 
which  in  a  few  cases  was  very  marked. 
This  increase  should  be  due  only  to  an 
increase  in  the  size  of  the  heart.  The 
symptoms  during  and  after  the  chlorosis 
allow  us  to  assume  that  the  heart  was 
dilated  and  hypertrophied.  In  some 
cases  the  enlargement  subsided  after  the 
symptoms  of  chlorosis  ceased;  more  fre- 
quently the  heart  remained  enlarged  for 
some  time  after,  and  slowly  attained 
normal  size.  The  causes  of  the  dilatation 
and  hj'pertrophy  culminate  in  those  of 
the  chlorosis  itself.  In  clilorosis  there  is 
a  diminution  of  the  functional  power  of 
the  heart;  the  normal  circulation  offers 
such  a  heart  unusual  difficulty,  and  in 
consequence  it  becomes  dilated  and 
hypertrophied.  In  chlorosis  tliere  is  a 
convincing  example  of  a  transitory 
hypertrophy.  The  pathogenesis  of  the 
cardiac  hypertrophy  in  chlorosis  indicates 
the  importance  of  congenital  or  acquired 
power  in  the  development  of  any  hyper- 
trophy of  the  heart.  Gautier  (Doutsclies 
Archiv  f.  klin.  Med.,  B.  02,  H.  1  and  2, 
'09). 
The  most  striking  symptom  is  the 
sallow  hue  of  tlie  skin  and  pale,  almost 
white,  color  of  lips  and  palpebral  con- 
junctiva. This  pallid  complexion  dif- 
fers from  that  of  the  so-called  wasting 
diseases,  such  as  cancer  and  phthisis,  in 
not  being  attended  with  emaciation.    In 


CHLOROSIS.    SYiMPTOSIS. 


91 


fact,  the  adipose  tissue  is  not  only  re- 
tained, but  persons  affected  with  chlo- 
rosis are  apt  to  put  on  flesh,  or,  rather, 
fat.  This  is  explained  by  the  fact  that, 
owing  to  the  greatly  reduced  amount  of 
hajmoglobin,  the  processes  of  oxidation 
in  the  body  are  carried  on  very  feebly. 

The  other  principal  symptoms  of  chlo- 
rosis are  lassitude  and  indisposition  to 
exertion,  loss  of  appetite,  and  other  di- 
gestive  disturbances,   and   constipation. 
The    dyspepsia    of    chlorosis    due,    as 
Hayem  first  pointed  out,  to  lack  of  hy- 
drochloric acid.      LiCgeois   (Revue  M6d. 
de  I'Est,  Sept.  15,  '91);  Labat   (Gaz.  de 
Hop.,   Dec.    30,   '90) ;    Chgron    (L'Union 
M6d.,  Dec.  9,  '90). 

Dyspepsia  in  chlorosis.  Seventy  eases 
of  chlorosis  examined;  an  excess  of  pep- 
sin found  in  36,  a  decrease  in  28;  an 
excess  of  hydrochloric  acid  in  6,  and 
normal  gastric  juice  in  2.  In  boys  and 
girls  at  the  age  of  adolescence  there  is 
commonly  some  dyspepsia  from  "hyper- 
pepsia,"  and  the  advent  of  chlorosis 
makes  this  prominent.  Hayem  (La  Sem. 
Mod.,  Nov.  4,  '91). 

Examinations  of  the  gastric  juice  of 
chlorotie  patients.  Conclusions:  1.  The 
amount  of  HCl  in  the  gastric  juiee  is  not 
diminished  in  cases  of  chlorosis;  on  the 
contrary,  there  i  a  state  of  hyperacidity 
in  i)o  per  cent,  of  the  cases.  2.  The  dys- 
peptic disorders  of  chlorosis  are  neither 
due  to  a  deficiency  of  HCl  nor  to  motor 
insulficiency  of  the  stomach.  3.  The  in- 
discriminate employment  of  hydrochloric 
acid  in  cases  of  chlorosis  is  to  be  con- 
demned. 4.  The  theories  Avhich  refer 
either  the  origin  of  chlorosis  or  its  chronic 
character  to  a  state  of  gastric  subacidity 
are  untenable.  K.  Osswald  (Miincli. 
mod.  Woch.,  July  3,  10.  '94). 

Among  the  ehloroses  due  to  autointoxi- 
cation is  one  which  clinical  and  thera- 
peutical observation  explains  as  a  thy- 
roid autointoxication.  Clinically  it  is 
characterized  by  the  usual  symptoms  of 
chlorosis,  to  which  are  added  a?dema 
similar  to  that  of  myxocdcma,  hyper- 
trophy of  the  thyroid  gland,  and  the 
signs  of  a  commencing  exophthalmic 
goitre.      Therapeutically    this    chlorosis 


disappears  under  treatment  by  iodothy- 
rin.    The  iodothyrin  was  administered  in 
tablets  of  4  grains  each,  of  which  from 
three   to  five  were  taken   per  day,   the 
amount  being  gradually  increased  for  a 
considerable  period,  and  then  decreased. 
Jeulain  (lied.  News,  Apr.  8,  '99). 
Xervous   symptoms,    such    as   hyper- 
jEsthesia,  neuralgia,  and  hysteria  are  not 
uncommon.     The  urine  is  pale,  of  low 
specific  gravity,  and  deficient  in  urea. 
"WTaile  menstruation  is,  as  a  rule,  either 
scanty  or  suppressed,  cases  are  now  and 
then  encountered  in  which  the  flow  is  so 
profuse  as  to  have  given  rise  to  the  term 
"chlorotie   menorrhagia."      Chlorosis   is 
sometimes  attended  by  febrile  symptoms. 
Fever  may  occur  in  the  course  of  chlo- 
rosis.    It  may  be  subdivided  into  three 
classes:    cases  with   (1)  continuous,   (2) 
intermittent,  and  (3)  inverted  fever.   The 
continuous  form  is,  perhaps,  commonest; 
the  intermittent — of  which  a  remarkable 
case,  with  wasting,  cough,  and  other  sus- 
picious symptoms,  occurred  in  the  prac- 
tice of  Jaceoud — is  least  so.    Paul  Chgron 
(L'Union  MCd.,  Dec.  9,  '90). 

Cases  of  pure  "febrile  chlorosis"  very 
rare,  the  cases  usually  so  regarded  being 
due  to  fatigue  or  other  complications. 
Hayem   (L'Union  JI6d.,  Dec.  9,  '90). 

But  one  case  met  with;  most  of  them 
are  due  to  constipation  and  absorption 
of  poisons  from  the  bowels.  Potain 
(L'Union  Med.,  Dec.  23,  30,  '90). 

A  febrile  type  of  chlorosis  does  not 
exist,  but  a  certain  degree  of  apyrexia 
accompanies  true  chlorosis.  Hence,  when 
fever  is  present,  it  must  be  attributed  to 
some  concomitant  morbid  state,  as  con- 
stipation or  tuberculosis.  E.  Guam  (II 
Morgagni,  Dec,  '94). 

None  of  the  symptoms  can  be  consid- 
ered pathognomonic.  As  to  the  color  of 
the  skin,  supposed  to  be  due  to  deficiency 
of  hiemoglobin,  the  general  view  is  in- 
correct, as  in  profound  ana?mia  there  is 
often  only  the  slightest  chemical  change 
in  the  blood,  while  with  no  apparent 
aniipmia  the  change  may  be  profound. 
There  are  other  coloring  matters  in  the 
blood  of  which  little  is  known,  and  it  is 
to  these  that  the  color  of  the  skin  is  due 


92 


CHLOROSIS.    COMPLICATIONS.    DIAGNOSIS. 


in  chlorosis.  Dyspnoea  and  headache  have 
also  been  attributed  to  deficiency  of  oxy- 
gen,   consequent    on    the    deficiency    of 
hsemoglobin;     but   deficiency   of   haemo- 
globin does  not  necessarily  diminish  the 
amount  of  oxygen  present;    it  has  been 
shown   that   there   may   be   even   more 
oxygen  than  normal  in  such  blood.    Great 
stress  should  be  laid  on  the  clear  appear- 
ance  of  chlorotic  blood;     it  is  to   this 
clearness,  due  to  some  anomaly  in  the 
blood-pigments,    in    which    haemoglobin 
plays  little  or  no  part,  that  the  color  of 
the  skin  is  due.    Biernaeki  (Wien.  med. 
Woch.,  No.  8,  '97). 
Complications. — There  are  certain  dis- 
eases to  which  chlorosis  stands  in  the 
relation   of   a   predisposing   cause,   and 
which,  therefore,  may  be  considered  as 
complications  or  sequels.     The  chief  of 
these  are  phthisis,  gastric  ulcer,  chorea, 
and  exophthalmic  goitre.    There  can  be 
no  doubt  that  one  of  the  best  prophy- 
lactic measures  against  phthisis  is  the 
maintenance  of  a  good  condition  of  the 
blood,  and  that,  conversely,  a  poor  state 
of   the   blood    may   be    regarded   as    a 
pretubercular   or   prebacillary   stage   of 
phthisis. 

Gastric  ulcer  is  by  no  means  uncom- 
mon in  chlorotic  women,  and  its  occur- 
rence is  favored  by  degenerative  changes 
in  the  blood-vessels  of  the  stomach,  lead- 
ing to  thrombosis  and  hasmorrhage  and 
subsequent  sloughing  in  the  mucous 
membrane  of  that  organ.  Chorea,  it  is 
well  known,  is  decidedly  more  common 
in  females  than  in  males,  and,  although 
more  frequently  observed  under  than 
over  fifteen  years  of  age,  is  yet  far  from 
being  rare  between  the  ages  of  fifteen 
and  twenty.  Its  occurrence  is  undoubt- 
edly favored  by  chlorosis.  The  same  is 
true  with  regard  to  that  peculiar  neu- 
roBiB  known  as  exophthalmic  goitre. 

Seven  caHcs  of  chloroHiH  complicated 
with  the  8i)27i8  and  Hymptoms  of  exoph- 
thalmic goitre,  the  latter  disappearing  as 
the  condition  of  tlie  blood  improved  and. 


therefore,  presumably  symptomatic.  F. 
Chvostek  (Centralb.  f.  "klin.  Med.,  Apr. 
14,  '94). 

When  the  aortic  valves  are  aflfected, 
chlorosis,  though  a  troublesome  compli- 
cation, does  not  aggravate  the  malady. 
Mitral  regurgitation,  on  the  other  hand, 
tends  to  be  exaggerated  by  a  chlorotic 
condition.  In  these  cases  iron  not  only 
augments  the  number  of  red  corpuscles, 
but  will  lead  to  a  greater  capillary  re- 
sistance, and,  consequently,  to  an  im- 
proved circulation.  Potain  (Jour,  de 
M6d.,  Aug.  14,  '95). 

Diagnosis. — The  diagnosis  of  chlorosis 
is  made  by  an  examination  of  the  blood 
and  a  careful  exclusion  of  organic  dis- 
ease. As  stated  under  the  anatomical 
characters  of  the  disease,  the  blood- 
changes  are  not  uniform.  There  is,  how- 
ever, usually  a  decided,  sometimes  a 
very  great,  decrease  in  the  percentage 
of  haemoglobin.  In  the  majority  of 
cases,  also,  if  the  disease  has  lasted  sev- 
eral weeks,  the  blood-corpuscles  are  di- 
minished in  number.  For  example,  in 
the  well-mai'ked  case  of  a  young  girl, 
aged  17,  whose  blood  I  recently  e.xam- 
ined,  I  found  the  following  condition: — 

No.  r.  c.  per  cubic  mm.,  2,690,000 
Hfflmoglobin 32  per  cent. 

The  percentage  of  red  corpuscles  as 
compared  with  the  healthy  standard 
(5,000,000)  was,  therefore,  54,  so  that 
the  value  of  each  corpuscle  (the  'Tiasmic 
unit")  was  only  -"/r,.,  of  the  normal,  mak- 
ing the  real  value  of  the  2,G90,000  cor- 
puscles only  equal  to  1,594,080.  Hayem 
gives  3,520,000  corpuscles  per  cubic 
millimetre  as  the  mean  of  18  counts, 
and  Coupland  about  3,000,000  as  the 
mean  of  7  counts.  There  are  conflict- 
ing statements  with  reference  to  the  size 
and  shape  of  the  red  corpuscles,  and 
there  can  be  no  doubt,  as  already  stated, 
that  they  may  be  normal  or  subnormal 
in  size. 


Appearance  of  the  Fundus  in   two  cases  of  Chlorosis, IC  A, Oliver) 


CHLOROSIS.     DIAGNOSIS. 


U3 


Bright's  disease,  which  is  often  very 
insidious  in  young  people  and  attendant 
with  great  anemia,  is  excluded  by  a 
careful  examination  of  the  urine. 

Chlorosis  is,  as  a  rule,  with  few  excep- 
tions, a  non-febrile  disease,  and,  there- 
fore, if  the  temperature  be  elevated, 
latent  tuberculosis  should  be  suspected. 
A  cardiac  murmur  should  not  be  hastily 
set  down  as  inorganic,  for  long-contin- 
ued anaemia  is  one  of  the  recognized 
causes  of  chronic  endocarditis. 

Cardiac    murmurs    appearing    in    the 
course    of    chlorosis    are    indicative    of 
gastrointestinal  disorders  that  influence 
the  volume  of  the  heart.    Nicolas  (Gaz. 
Hebdom.  de  M6d.  et  de  Chir.,  Jan.   II, 
1900). 
The  blood  diseases  from  which  chlo- 
rosis should  be  differentiated  are   the 
following: — 

Pkrnicious  ANiEMiA. — In  this  affec- 
tion the  skin  is  more  yellow  than  green- 
ish. Blood-examination  shows  a  relative 
increase  of  hsemoglobin  and  the  pres- 
ence of  gigantoblasts;  there  is  also 
marked  oligocythemia. 

LEUCOOYTHiEMiA.  —  The  microscope 
shows  the  characteristic  increase  of  white 
corpuscles,  their  ratio  to  the  red  cor- 
puscles becoming  sometimes  1  to  30  in- 
stead of  1  to  600,  the  usual  proportion. 
LEUKiEMiA. — The  facial  discoloration 
is  much  less  marked  and  the  lips  are  red, 
instead  of  pale  as  in  chlorosis. 

HoDG kin's  Disease. — In  this  affec- 
tion the  glandular  enlargement  is  more 
or  less  marked,  and  serves  to  easily  dif- 
ferentiate it  from  chlorosis,  in  which  the 
lymphatic  glands  do  not  play  a  special 
r61e  in  the  general  dyscrasia. 

Warning  against  hasty  diagnosis  of 
chlorosis  from  mere  inspection.  There 
are  various  deceptive  features,  including 
certain  anoesthesias  and  analgesias,  com- 
parable to  those  of  hysteria,  but  not  to 
be  confounded  with  such.  Asthma  is 
a  common  symptom.     The  disease  has 


been  growing  more  infrequent,  owing  to 
the  better  hygienic  conditions  of  our 
time.  Potain  (L'Union  M6d.,  Dec.  23, 
30,  '90). 

Examination  of  the  fundus  frequently 
elicits  a  lustreless,  dull,  and  grayish  ap- 
pearance of  the  optic  nerve,  when  the 
htemoglobin  is  greatly  reduced.  Inflam- 
mation of  the  optic  nerve  is  occasionally 
observed. 

Emphasis  on  the  statement  that  there 
is  in  chlorosis  a  greater  tendency  to  in- 
flammation of  the  optic  nerve  and  retina 
than  in  pernicious  anaemia,  while  the 
tendency  to  retinal  hoemorrhage  is  con- 
siderably less.  The  latter  fact  Is  notori- 
ous, but  the  former  is  not  so  generally 
recognized.  Stephen  Mackenzie  (Clinical 
Jour.,  Jan.  10,  '94). 

A  case  in  a  girl,  aged  21,  in  which 
optic  neuritis  occurred  in  the  course  of 
chlorosis.  Dieballa  {Deut.  med.  Woch., 
July  9,  '96). 

While  examination  of  the  fundus  often 
gives  indications  of  anjemia,  it  does  not 
always  do  so,  especially  in  cases  of 
anceniia  of  moderate  degree.  In  chlo- 
rosis ocular  manifestations  are  more  fre- 
quent than  was  commonly  supposed,  for, 
in  nearly  every  case  in  which  the  htemo- 
globin  is  markedly  reduced,  changes  in 
the  fundus  may  be  found.  The  most 
common  change  is  a  dull,  lustreless,  gray- 
ish appearance  of  the  nerve.  In  per- 
nicious anaemia  clinicians  have  observed 
retinal  hoemorrhages,  but  they  are  not 
so  uniformly  present  as  some  have  sup- 
posed. As  a  rule,  they  occur  in  the  ad- 
vanced stage.  In  initial  antemia  from 
loss  of  quantity  of  blood  there  are  seldom 
ocular  changes  unless  some  other  factor 
than  loss  of  blood  exists.  W.  C.  Posey 
(N.  Y.  Med.  lice,  July  10,  '97). 

JIarked  case  of  chlorosis  in  which  the 
fundus  was  examined:  The  surface  of 
the  disc  was  of  mottled  yellowish  white. 
Its  edges  were  hazy  and  at  places  were 
almost  indiscernible.  The  fibre-layer  of 
the  retina,  which  itself  was  visible  to 
a  more  or  less  degree  throughout  the 
fundus,  was  thickened,  opaque,  and  in- 
tensely striated.  The  underlying  choroid, 
so  unlike  that  which  is  so  common  in 


94 


CHLOROSIS.    ETIOLOGY. 


the  negro  race,  was  but  sparingly  and  ir- 
regularly pigmented.  The  retinal  veins 
and  arteries,  particularly  the  former, 
were  pallid,  with  a  thickening  and  pro- 
nounced opacification  in  many  places  of 
their  lymph-sheath  walls.  To  the  nasal 
side  of  the  disc  two  (aintly -marked 
lymph-massings  could  be  dimly  seen. 
{See  colored  plate,  Fig.  I.) 

The  fields  of  vision  for  white  and  red, 
especially  the  former,  as  shown  in  sketch 
2,  were  markedly  contracted. 

Careful  testing  and  retesting  of  the 
urine  failed  to  show  any  course  disturb- 
ance or  evidence  of  general  dyscrasia. 

Examination  of  the  blood:  The  red 
cells  amounted  to  but  1,GOS,000,  and  the 
white  ones  were  decreased  to  3490.  The 
haemoglobin  equaled  but  22  per  cent. 
The  red  cells  were  quite  irregular  in  size, 
both  microcytes  and  macrocj'tes  being 
present.  A  few  nucleated  red  cells  could 
be  seen,  but  there  were  some  of  all  types. 
None  of  them  could  be  determined  to  be 
in  the  process  of  cell-division. 

E.\amination  of  the  ejes  of  a  case  of 
chlorosis,  while  the  blood  showed  that 
the  red  corpuscles  were  as  low  as  300,000, 
the  whites  2500,  and  the  heemoglobin  re- 
duced to  24  per  cent.,  nucleated  red 
corpuscles  being  present.  The  pupils 
were  of  the  same  size.  The  irides  re- 
sponded equally  to  light-stimulus.  There 
was  a  marked  tremor  of  the  orbicularis 
muscle  of  the  right  eye.  The  fields  of 
vision,  as  well  as  could  be  taken,  were 
reduced  concentrically.  The  eye-grounds 
were  about  the  same  on  each  side.  There 
was  a  disposition  to  hsemorrhages  into 
the  retina  that  were  characteristic  of 
both  the  Quincke  and  the  Horner  types. 
The  disc  was  pallid.  The  retina  was 
somewhat  oedematous  in  the  naso-macu- 
lar  region.  The  larger  hoemorrhages, 
which,  as  a  rule,  were  deeply  seated  be- 
neath the  fibre-layer  of  the  retina,  pre- 
sented both  white  and  grayish  centres, 
and,  as  shown  in  the  figure,  one  envel- 
oped a  portion  of  the  lower  temporal 
vein.  More  careful  study  made  it  ap- 
parent that  a  few  of  the  white  areas  in 
the  hajmorrhagcH  were  due  to  leuco- 
cytic  aggregation,  though  tlie  bulk  of 
them  were  dependent  upon  tissue-de- 
generation.     {Hee  colored  plate,  Flu.  IT.) 


Charles  A.  Oliver  (Trans.  Amer.  Ophth. 
Soc,  '97). 

Etiology. — The  chief  predisposing 
causes  of  chlorosis  are  to  be  found  in 
sex,  age,  and  constitution.  The  forces 
emanating  from  these  sources  come  to  a 
focus,  so  to  speak,  in  a  case  of  chlorosis 
and  that  which  brings  them  to  a  focus 
in  the  advent  of  puberty.  The  principal 
of  these  predisposing  causes  is,  I  be- 
lieve, a  congenital  tendency  to  anjemia. 
Some  years  ago,  while  examining  the 
blood  of  the  new-born  at  the  Maternity 
Hospital,  I  discovered  an  infant  whose 
red  blood-corpuscles  numbered  only 
3,625,000  per  cubic  millimetre,  the  nor- 
mal average  being  at  least  5,000,000. 
Now,  this  child  which,  by  the  way,  was 
a  female,  might,  under  proper  treatment, 
thrive  until  tlie  age  of  puberty,  when  the 
demands  made  upon  the  blood  by  the 
evolution  of  the  sexual  system  would,  in 
all  probability,  give  rise  to  well-marked 
chlorosis.  The  chief  predisposing  causes 
of  chlorosis  are,  I  repeat  (1)  sex,  the  vast 
majority  of  cases  occurring  in  females; 
(2)  age,  the  decade  between  fourteen 
and  twenty-four  furnishing  most  of  the 
cases;  (3)  constitution,  either  inherited 
or  acquired. 

True  chlorosis,  when  not  traceable  to 
external  injury  or  to  a  primary  disease, 
is  a  disorder  of  development,  like  any 
other  such  disorder  or  sign  of  physical 
degeneracy.  It  is  very  frequently  asso- 
ciated with  infantile  types  of  structure 
in  the  adult  patient,  especially  ill-devel- 
oped pelvis,  labia,  uterus,  pudendal  hair, 
and  breasts.  Stieda  (Zeit.  f.  GebUrtsh. 
u.  Gynilk.,  B.  32,  H.  1,  '05). 

Chlorosis  is  the  result,  not  the  cause, 
of  amenorrhoee:  a  menstrual  autointoxi- 
cation. Immediately  before  the  period 
the  toxicity  of  the  serum  is  at  a  maxi- 
mum. Wet-nurses  who  menstruate  dur- 
ing lactation  are  apt,  during  the  days 
preceding  the  show  of  blood,  to  cause 
their  'sneklingH  to  Huffer  from  diarrlinea 
and  cutaneous  eruptions.      Such  women 


CHLOROSIS.     ETIOLOGY. 


95 


themselves  often  have  herpes  and  fever. 
Menstruation  is  a  true  excretory  process: 
a  purging  of  waste-products.  Charrin 
(M6d.  Mod.,  Jan.  11,  '90). 

Chlorosis  looked  upon  as  the  symptom 
of  a  general  neurosis,  in  which  many 
other  symptoms  arise  through  the 
anoemic  blood.  Altered  composition  of 
the  blood  ascribed  to  a  morbid  function  of 
the  vasomotor  nerves,  which  gives  rise  to 
polyplasmia,  lymph-congestion,  and  im- 
perfect development  of  red  blood-cor- 
puscles. That  chlorosis  is  essentially  a 
disease  of  puberty  may  be  explained  by 
the  fact  that,  at  the  time  of  development 
of  the  female  sexual  organs,  the  vaso- 
motor nerves  are  especially  disposed  to 
disease,  just  as,  in  still  earlier  periods, 
the  motor  functions  are  prone  to  affec- 
tion, as  in  chorea.  E.  Grawitz  (Fort- 
schritte  der  Med.,  Berlin,  No.  3,  '98). 

The  family  history  of  36  cases  of  chlo- 
rosis studied  during  the  last  five  years 
to  ascertain  the  connection  between 
chlorosis  and  tuberculosis.  In  1890 
Jolly  concluded  from  an  examination  of 
54  cases  that  in  the  majority  of  in- 
stances a  personal  or  family  history  of 
scrofula  or  tuberculosis  was  to  be  found. 
The  36  cases  now  recorded,  however, 
show  that  tuberculosis  has  not  any 
more  influence  in  the  causation  of  chlo- 
rosis than  have  other  pathological 
states.  The  influence  of  hereditary  tu- 
berculosis is  only  exerted  by  enfeebling 
the  stock.  Leclerc  and  Levet  (Lyon 
M6d.,  Aug.  4,  1901). 

Exciting  Causes. — The  exciting 
causes  of  chlorosis  are  those  of  anajmia  in 
general,  such  as  insufficient  food,  light, 
air,  and  exercise;  overwork,  either  phj's- 
ical  or  mental;  anxiety,  grief,  and  nerv- 
ous excitement  in  general.  There  is 
another  exciting  cause  on  which  great 
stress  was  laid  by  the  late  Sir  Andrew 
Clark  and  which,  therefore,  deserves  to  be 
considered  at  some  length.  The  cause  to 
which  I  refer  is  constipation,  and  Clark 
regarded  it  of  such  paramount  impor- 
tance that  he  used  tlie  term  f,T>cal  anremia 
as  a  synonjTn  of  chlorosis.  Tliis  theory  of 
Clark  is  based  upon  certain  signs  and 


symptoms  that  are  commonly  encount- 
ered in  chorosis.  Chief  among  them  are 
digestive  disturbances.  The  tongue  is 
generally  heavily  coated  at  the  base, 
large,  flabby,  and  with  its  sides  indented 
with  the  teeth.  The  breath  is  disagree- 
able and  sometimes,  according  to  Clark, 
has  a  distinctly  fsecal  odor.  The  bowels 
are  either  confined  or  inadequately  re- 
lieved, and  the  fceces  consist  of  scybalous 
masses  imbedded  in  mucus  swarming 
with  bacteria.  Pain  in  the  side,  most 
marked  on  the  left,  is  a  common  symp- 
tom, and  is  believed  by  Clark  to  have 
its  seat  either  in  the  hepatic  or  splenic 
flexure  of  the  colon.  This  view  of  the 
nature  of  the  pain  in  the  side  is  corrob- 
orated by  the  fact  that  it  may  be  relieved 
by  large  enema  ta  of  warm  water.  Accord- 
ing to  the  authority  just  named,  it  is  a 
common  thing  for  young  girls  to  neglect 
the  calls  of  nature,  so  far  as  the  bowels 
are  concerned.  The  faeces  accumulate, 
and,  by  their  decomposition,  ptomaines 
and  leucomaines  are  generated,  absorbed, 
and,  by  their  poisonous  action,  produce 
the  multiform  symptoms  of  chlorosis. 
A  treatment  based  upon  the  theory  that 
chlorosis  is  due  to  fascal  retention  is 
sometimes  eminently  successful,  and  will 
be  referred  to  later  in  detail. 

Three  cases  of  chlorosis  characterized 
by  the  presence  in  the  urine  of  a  pe- 
culiar "chroniogen" — a  colorless  sub- 
stance which  becomes  converted  into  a 
pigment  of  oxidation.  It  is  manifested 
by  the  urine  becoming  a  rose-red  color 
on  the  addition  of  nitrous-nitric  acid: 
I.e..  pure  nitric  acid  to  which  a  small 
quantity  of  the  common  yellow  acid  of 
commerce  has  been  added.  Chromogcn 
is  a  derivative  of  skatol,  and.  therefore, 
derived  from  foecal  absorption.  In  all 
cases  there  was  marked  constipation,  the 
relief  of  which  by  large  enemata  consti- 
tuted the  basis  of  his  treatment.  Res- 
toration to  health  coincided  with  disap- 
pearance    of     the     urinary    chromogcn. 


96 


CHLOROSIS.    ETIOLOGY. 


George    Herschell     (Practitioner,    May, 
'93). 

Chlorosis  is  of  intestinal  origin.    Dim- 
inution   of    urobilin    in    the    lu-ine    an 
important  sign.    A  toxic  body  foimd  in 
the  urine,  "the  exact  nature  of  which  it 
has  been  as  yet  impossible  to  determine," 
but  which  is  believed  to  be  largely  ac- 
coimtable  for  the  nervous  phenomena  of 
chlorosis.    F.  Forchheimer  (Therap.  Gaz., 
Xov.  15,  '93). 
Another  exciting  cause  of  chlorosis  is 
cold.    Prof.  Augusto  Murri,  of  Bologna, 
has  published  an  elaborate  paper  on  the 
influence  of  cold  in  the  etiology  of  chlo- 
rosis.   He  gives  the  notes  of  three  cases, 
in  which  the  symptoms  of  the  disease 
were  limited  to  the  cold  months  of  the 
year,   disappearing  in   summer  and   re- 
curring at  the  onset  of  the  succeeding 
winter,  and  he  states  that  others  pre- 
cisely similar  have  come  under  his  ob- 
servation.    He,   therefore,   styles  them 
"winter  chlorosis,"  or  chlorosis  hiemalis. 
It  is  well  known  that  chlorotic  patients 
are  often  affected  unfavorably  by  such 
exposure  to  cold  as  is  well  borne  by  the 
healthj',  and  this  Murri  believes  to  be 
due  to  an  instability  of  the  vasomotor 
system  on  the  part  of  the  former.     In 
fact,  he  regards  chlorosis  as  a  vasomotor 
neurosis,  the  blood-changes  in  the  dis- 
ease   being   induced    by   cold,    nervous 
shock,  or  long-continued  irritation  from 
the  genital  organs  or  elsewhere. 

Meinert,  of  Dresden,  claims  to  have 
demonstrated  a  displacement  of  the 
stomach  (gastroptosis)  in  sixty  consec- 
utive cases  of  chlorosis.  Fifteen  per 
cent,  of  the  cases  were  complicated  with 
right  movable  kidney  and  in  one  case 
both  kidneys  were  movable.  The  gas- 
troptosis is  secondary  to  enteroptosis 
and  this,  in  turn,  to  the  pressure  of  the 
corset;  so  that,  according  to  Meinert,  it 
is  to  this  article  of  female  apparel  that 
chlorosis  is  due.  After  the  cure  of  a 
case   of   chlorosis,   its   anatomical    sub- 


stratum, the  visceral  displacement,  re- 
mains, and  hence  the  notorious  tendency 
of  the  affection  to  relapse. 

No  one  doubts  the  evil  effect  of  tight- 
lacing,  and  all  will  admit  that  in  a  per- 
son predisposed  by  inheritance  or  other- 
wise to  chlorosis  the  development  of  the 
disease  may  be  accelerated  by  constric- 
tion of  the  thoracic  base  and  consequent 
displacement  of  viscera. 

Chlorotic  subjects  often  present  a  high 
position  of  the  diaphragm.  The  liver- 
dullness  begins  at  the  upper  edge  of  the 
fourth  or  the  lower  edge  of  the  third  rib. 
The  heart-dullness  is  sometimes  found  to 
extend  either  to  the  right  or  to  the  left. 
This  enlargement  of  the  area  of  the  heart- 
dullness  is  probably  due  in  but  a  few 
cases  to  dilatation.  Fi-equently  it  is  of 
a'  certainty  due  to  the  elevated  position 
of  the  diaphragm,  in  consequence  of  the 
diminislied  volume  of  the  lungs.  F. 
Mijller  (Berl.  klin.  Woch.,  Sept.  23,  '93). 

In  a  series  of  29  cases  dilatation  of 
stomach  without  retention  found  in  8 
cases;  dilatation  of  stomach  with  re- 
tention found  in  6  cases;  flatulent  dys- 
pepsia in  14  cases.  Chlorotic  patients 
are  more  concerned  with  the  pale  color, 
breathlessness,  swelling  of  the  feet,  and 
palpitation  than  with  gastric  disturb- 
ances. In  17  cases,  however,  dyspepsia 
preceded  the  chlorosis;  in  2  cases  both 
appeared  simultaneously,  and  in  the  re- 
mainder the  relation  could  not  be  deter- 
mined. Mongour  (Archives  Clin,  de 
Bordeaux,  Nov.,  '9G). 

As  to  Meinert's  contention  that  chlo- 
rosis is  produced  by  the  gastroptosis 
brought  about  by  the  pressure  of  the 
corset:  It  may  be  possible  to  define  the 
outline  of  the  stomach  in  cases  of  con- 
siderable gastroptosis  where  the  upper 
curvature  lies  below  the  liver  and  the 
abdominal  walls  are  lax;  but  in  young 
subjects,  such  as  chlorotic  girls,  the  chlo- 
rotic walls  are  not  lax.  In  a  large  num- 
ber of  chlorotics,  who  wore  corsets,  to 
map  out  tlie  lesser  curvature  of  the 
stomach  was  found  impossible.  It  is 
UHiial,  however,  in  such  cases  to  find  the 
greater  curvature  extending  lower  down 
than  usual;    this  is  possibly  due  to  an 


CHLOROSIS.  PROGNOSIS.  PATHOLOGY. 


97 


abnormal  distensibility  of  the  stomach: 
a  condition  occurring  as  a  result  of  chlo- 
rosis.   Leo  (Deut.  med.  Woch.,  Mar.  19, 
'90). 
There  are  those  who  regard  chlorosis 
as  an  infectious  disease.     Chief  among 
them   is   Clement,    of   the   Hotel-Dieu, 
Paris,  who  bases  his  opinion  of  its  in- 
fectious nature  on  the  enlargement  of 
the  spleen,  which  he  has  found  in  thir- 
teen cases;    on  the  frequency  of  fever, 
the   occasional   complication   of   phleg- 
masia dolens,  and  the  epidemic  occur- 
rence of  the  affection.     The  hypothesis 
is  well  argued,  but  the  facts  upon  which 
it  is  based  are  questionable. 

Blood  of  chlorotie  patients  exaiiiined 
for  micro-organisms,  and  in  ten  or  twelve 
cases  either  the  streptococcus  albus  or 
the  staph3'lococeus  albus  found,  the 
former  being  the  more  abundant,  and — 
in  rarer  instances — the  bacillus  coli. 
Lemoine  (Le  ProgrSs  M6d.,  Nov.  17,  '94). 
Thrombi  ma.y  form  in  the  cerebral 
sinuses  and  cervical  veins,  though  usu- 
ally they  occur  in  the  femoral  vein.  They 
necessarily  cause  death;  the  two  recorded 
instances  of  thrombi  in  the  jugular  vein 
ended  in  recovery.  Infection  the  cause. 
Bourdillon  (Jour,  de  MOd.  et  de  Chir. 
Prat.,  8ept.  10,  '92). 

Enlargement  of  the  spleen  observed  in 
twenty-one  out  of  fifty-six  cases  of  chlo- 
rosis. Inasmuch  as  a  "foetal  state"  of 
the  spleen,  marrow,  and  other  h£emnto- 
poietic  organs  has  been  described  as  char- 
acteristic of  chlorosis,  this  observation  is 
interesting.  F.  Chvostek  (Allgemeine 
med.  Central-Zeitung,  July  22,  '92). 

Study  of  thirty-one  cases:  Chlorosis 
is,  in  the  great  majority  of  cases,  the  re- 
sult of  mnlnjitrition.  dependent  vipon  the 
consumption  of  an  insufficient  amoimt 
or  of  an  unsuitable  quality  of  proteid; 
in  most  cases  a  great  diminution  of  the 
nitrogenous  excreta  of  the  urine  found, 
while  a  common  symptom  of  chlorosis 
is  a  perversion  of  the  appetite  to  the 
excessive  consumption  of  starches  and 
sugars.  The  superiority  of  such  prepara- 
tions as  ferratin  over  the  inorganic  forms 
of  iron  suggests  that  there  is  value  in 
the  proteid  material  which  they  contain. 


Simon    (Amcr.  Jour,   of  Med.  Sciences, 
Apr.,  '97). 

Chlorosis  is  due  to  a  transient  inca- 
pacity of  the  blood-forming  organs  oc- 
curring during  puberty,  or  to  an  hypo- 
plasia of  those  organs,  manifesting  itself 
more  or  less  throughout  life,  and  occa- 
sionally resulting  in  the  hypoplasia  of 
the  vessels  described  by  Virchow.  This 
weakness  of  the  blood-forming  apparatus 
manifests  itself  in  the  production  of  less 
valuable  erythrocytes,  deficient  in  hcemo- 
globin  and  altered  in  form.  Hofmann 
(Munchener  med.  Woch.,  July  18,  '99). 

Prognosis. — The  prognosis  of  uncom- 
plicated chlorosis  is  invariably  good, 
the  response  to  appropriate  treatment 
being  prompt  and  decided.  It  should 
be  borne  in  mind,  however,  that  inter- 
current disease  of  any  kind  is  apt  to  be 
unusually  severe.  Tiiis  is  especially 
true  with  reference  to  febrile  disorders, 
which  occasion  great  and  rapid  consump- 
tion of  the  blood-corpuscles  in  healthy 
persons.  As  a  matter  of  course,  the 
powers  of  resistance  to  such  affections 
are  much  reduced  in  those  whose  blood 
is  already  impoverished.  In  forming  a 
prognosis  the  tendency  of  the  disease  to 
relapse  should  not  be  forgotten.  This  is 
especially  marked  in  those  cases  in  which 
the  development  of  the  vascular  and  re- 
productive sj'stems  is  imperfect;  in  other 
words,  in  those  in  whom  the  tendency 
to  anaemia  is  congenital.  Predictions  of 
permanent  cure  after  a  single  course  of 
treatment  should,  therefore,  be  made 
with  great  reserve  or,  better  still,  should 
not  be  made  at  all. 

Pathology. — Virchow  endeavored  to 
place  chlorosis  upon  a  distinct  anatomi- 
cal basis  by  the  demonstration  that,  in 
fatal  cases,  there  is  often  found  an  im- 
perfect development  of  the  aorta  and 
arterial  system  generally.  He  has  found 
the  aorta  of  a  full-grown  woman  so 
small  as  barely  to  admit  the  little  finger, 
whereas,  normally,  it  should  admit  the 


a-7 


98 


CHLOROSIS.     PATHOLOGY. 


ttumb,  and,  with  this  condition  of  the 
liunen  of  the  vessel,  its  coats  were  found 
to  be  much  thinner  than  normal.  He 
regards  this  condition  of  the  vessels  as 
congenital,  and  the  importance  of  the 
observation  depends  upon  the  fact  that 
the  blood-vessels  and  the  blood-cor- 
puscles are  both  derived  from  the  same 
embrj'onic  layer, — the  mesoblast, — an 
imperfect  development  of  the  one  nec- 
essarily entailing  the  same  condition 
of  the  other.  There  is  little  doubt  that 
Virchow's  observation  is  true  with  ref- 
erence to  some  of  the  cases,  especially 
those  that  run  a  fatal  course.  A  con- 
dition of  imperfect  development  of  the 
vascular  system  might,  doubtless,  give 
rise  to  grave  disturbances  of  nutrition 
eventually  ending  in  death;  but  chlo- 
rosis is  not  a  fatal  disease,  the  great  ma- 
jority of  cases  under  appropriate  treat- 
ment terminating  in  recovery,  and  with 
reference  to  them  there  is  no  proof  that 
such  a  stunted  condition  of  the  blood- 
vessels is  present. 

The  only  constant  anatomical  changes 
of  chlorosis  are  those  of  the  blood  itself, 
and  it  is  for  this  reason  that  the  disease 
is  classed  among  the  primary  ansemias. 
Even  the  blood-changes  are  not  uniform. 
The  researches  of  Duncan  in  1S67  first 
established  the  fact  that,  in  well-marked 
cases  of  chlorosis,  the  number  of  red 
corpuscles  might  be  normal,  while  their 
percentage  of  haemoglobin  might  be 
greatly  reduced,  and  this  anomaly  was, 
for  a  long  time,  regarded  as  the  dis- 
tinguishing mark  of  chlorosis.  It  has 
since  been  establi.shed  that  this  view  of 
the  blood-change  in  chlorosis  is  alto- 
gether too  narrow,  and  at  the  present 
day  it  is  generally  admitted  that  the 
blood-changes  in  chlorosis  may  be  at 
least  threefokl:  1.  They  may  be  of  nor- 
mal size  and  number,  their  only  change 
being  a  deficiency  of  haemoglobin.     2. 


They  may  be  diminished  in  number, 
with  diminished  percentage  of  hcemoglo- 
bin.  3.  They  may  be  diminshed  in  size 
and  normal  in  number  and  in  percent- 
age of  hEemoglobin.  Of  these  varieties, 
the  second  is  the  most  severe,  and  in  it 
there  are  often  marked  changes  (poiki- 
loeytosis)  in  the  shape  of  the  red  cor- 
puscles, such  as  are  so  commonly  ob- 
served in  pernicious  anaemia. 

From  these  facts  it  is  evident  that 
there  is  nothing  uniform  in  the  be- 
havior of  the  red  corpuscles  in  the  dis- 
ease called  chlorosis;  so  that  an  attempt 
to  describe  it  as  a  distinct  disease  from 
an  anatomical  stand-point  must  result  in 
failure.  The  essential  point  is  that  the 
percentage  of  hasmoglobin  is  reduced, 
but  this  is  common  to  many  forms  of 
ana3mia. 

Chlorosis  is  due  to  oligoclirorasemia, 
the  result  of  faulty  htemopoiesis,  in  turn 
due  to  diminished  htemoglobin  produc- 
tion. HfEmoglobin  is  principally  formed 
in  the  intestine;  this  is  proved  (a)  by 
direct  investigation  upon  lower  animals, 
and  {&)  by  direct  observation  upon  the 
human  being.  Hfemoglobin  formation 
can  be  increased  by  the  introduction  into 
the  intestine  of  agents  not  containing 
iron,  but  preventing  putrefaction.  Chlo- 
rosis is  due  to  a  prevention  of  hfemo- 
globin formation  by  destructive  agents 
acting  upon  the  precursor  of  hsemoglobin 
in  the  intestine.  Forchhcimer  (Boston 
Med.  and  Surg.  Jour.,  Aug.  24,  '03). 

The  albumin  is  diminished,  owing  to 
the  diminution  of  hmmoglobin;  the  rela- 
tion of  albumin  to  globulin  is  normal 
and  the  amount  of  fibrin  increased. 
There  is  considerably  more  fat  than  nor- 
mal in  both  tlie  serum  and  tlie  erythro- 
cytes; the  lecithin  is  diminished  in  the 
total  blood  and  the  seriun,  but  seems 
to  be  increased  in  the  red  cells.  Choles- 
terin  is  present  in  smaller  amoimts  in 
both  the  scrum  and  red  cells.  In  the  ash, 
phosphoric  acid,  potassium,  and  iron  are 
considerably  reduced,  calcium  and  mag- 
nesium are  increased.  The  increase  of 
sodium  chloride  is  only  apparent,  since 


CHLOROSIS.     TREATMENT. 


99 


chlorotic  blood  contains  a  higher  per- 
centage of  serum  than  normal  blood; 
the  amount  of  sodium  chloride  in  the 
serum  is  not,  however,  increased.  F. 
Erben  (Zeitsch.  f.  klin.  Med.,  vol.  xlvii, 
Nos.  3  and  4,  1903). 

It  has  been  contended  by  some  writers, 
especially  by  Immermann,  that  chlorosis 
dillers  from  all  other  forms  of  anaemia 
in  that  the  albuminous  bodies  of  the 
blood-serum  are  present  in  that  fluid  in 
normal  or  increased  amount.  This  has 
certainly  been  proved  to  be  true  in  a 
few  cases  by  chemical  examination,  but 
it  has  not  yet  been  proved  that  the  same 
may  not  be  true  of  other  forms. 

From  the  above  it  appears  evident 
that  the  conditions  of  the  blood  and  the 
other  organs  of  the  body  are  so  various 
as  to  veto  the  present  establishment  of 
chlorosis  as  a  disease  with  a  distinct  ana- 
tomical basis.  With  advancing  knowl- 
edge, some  etiological  or  pathological 
fact  common  to  all  eases  of  the  affec- 
tion may  be  discovered,  but  at  present 
none  such  is  known.  With  our  present 
knowledge,  the  most  sensible  view  of  the 
nature  of  chlorosis  appears  to  me  the 
following,  which  I  have  already  ex- 
pressed elsewhere:  At  the  time  of  pu- 
lierty  there  is  an  urgent  physiological 
demand  upon  the  blood,  which  is  com- 
plied with  by  vigorous  persons  without 
detriment  to  the  organism.  The  ordeal 
of  puberty  is  safely  passed.  In  less  vig- 
orous, but  still  sound,  healthy  organisms 
a  decided  degree  of  anaamia,  one  calling 
for  treatment,  declares  itself  at  this 
time.  Finally,  in  those  with  any  con- 
genital tendency  to  anasmia,  whether  this 
be  due  to  general  malnutrition  during 
intra-uterine  life  or  to  a  special  hypo- 
plasia of  the  vascular  system,  the  an- 
femia  of  puberty  is  intense;  the  case 
is  a  typical  one  of  chlorosis. 

Cases  of  chlorosis  may  lie  divided  into 
three   classes:     (1)    Chlorosis  with   vas- 


cular hypoplasia  without  change  in  the 
se.xual    apparatus;     (2)    chlorosis    with 
vascular  hypoplasia  and  excessive  devel- 
opment of  the  genital  apparatus;     (3) 
chlorosis  with  vascular  liypoplasia  and 
defective  development  in  the  genital  ap- 
paratus.    Even  though  later  researches 
may  show  that  the  vascular  hypoplasia 
is  not  constant,  the  lesions  of  the  ves.sels 
and  the  heart  will  occupy,  nevertheless, 
a   prominent   place   in   the   pathological 
anatomy  of  chlorosis.     Gilbert,  of  Paris 
(Moil.  Record,  Oct.  2,  '97). 
Treatment. — As  Immermann  remarks, 
"there  is  scarcely  any  point  in  thera- 
peutics so  fully  established  as  the  re- 
markable efficiency  of  iron  in  removing 
all  the  symptoms  of  chlorosis";    but  it 
does  not  follow  that  iron  should  initiate 
the  treatment  in  every  case.     Nearly  all 
chlorotics  are  dyspeptic,  and  until  the 
digestive   disorder  is  relieved   the   full 
benefit  of  iron  cannot  be  obtained.    In 
cases  of  atonic  dyspepsia,  the  simple  bit- 
ters, such  as  quassia  or  gentian  or  ex- 
citers  of   the   smooth   muscular   fibres, 
such  as  strychnine  or  brucia,  may  be 
administered  before  meals  or,  if  there  is 
gastric    dilatation,    naphthol,    bismuth 
salicylate,  or  chloroform-water  may  be 
administered  three  or  four  hours  after 
meals,  as  recommended  by  le  Gendre, 
in  order  to  arrest  the  abnormal  fermen- 
tations usually  present  in  that  condition. 
Lavage  is  rarely,  if  ever,  necessary.    Hy- 
peracidity of  the  gastric  juice  should  be 
treated  with  full  doses  of  alkalies — soda, 
chalk,    lime-water,    or    magnesia — from 
one  to  two  hours  after  meals  and  ana- 
cidity  with  full  doses  of  dilute  hydro- 
chloric acid  immediately  after  eating. 

The  dyspeptic  disorders  so  often  met 
with  may  become  a  serious  obstacle  to 
active  treatment:  such  cases  should  be 
looked  upon  and  treated  as  simple  dys- 
pepsias, until  the  stomach  be  brousht 
into  condition  for  the  treatment  of  the 
chlorosis  itself.  Hayem  (La  Scm.  Miki., 
Xov.  4.  '91). 

The  first  object  is  to  improve  the  gen- 


100 


CHLOROSIS.     TREATMENT. 


eral  condition,  then  exercise  in  the  open 
air.  A.  Hoessli  (Deut.  med.  Woch.,  Sept. 
15,  '92). 

Such  mUd  laxatives  as  compound  lioo- 
rice-powder  and  cream  of  tartar.  The 
preparation  of  iron  used  will  depend 
upon  individual  conditions.  Blaud's  pill 
and  the  tincture  of  the  chloride  of  iron 
are  preferred.  Arsenic  ought  not  to  be 
used  alone,  but  forms  a  good  adjuvant, 
especially  in  the  form  of  arsenical  waters, 
like  the  Koncegno  or  Levico.  Sulphur, 
so  highly  lauded  by  Schultz,  acts  prob- 
ably by  stimulating  the  bowels.  Noth- 
nagel  (Wiener  med.  Presse,  No.  52,  '92). 

Sulphur  bears  very  intimate  relations 
to  cellular  protoplasm,  and  acts  in  a 
more  important  manner  in  chlorosis  than 
as  a  mere  laxative.  It  is  indicated  when 
iron  does  not  seem  to  act  and  when  there 
is  not  gastro-intestinal  irritation.  After 
it  has  been  used  for  a  time,  iron  may 
again  be  administered  instead,  and  with 
better  hope  of  success  than  before  the 
sulphur  was  used.  Schultz  (Berliner 
klin.  Woch.,  Mar.  28,  '92). 

Dietetic  treatment  of  chlorosis.  This 
should  vary  somewhat,  according  to 
whether  the  patient  is  lean  or  fat.  Lean 
patients  sliould  be  given  food  "copious  in 
quantity  and  favoring  the  deposit  of  adi- 
pose tissue."  This  includes  large  quanti- 
ties of  butter  and  such  "amylaceous 
foods  as  do  not  irritate  the  stomach," 
and  about  3  ounces  of  meat  per  diem. 
Unnecessary  muscular  exertion  and  ex- 
posure to  cold  should  be  forbidden,  and 
in  some  cases  absolute  rest  may  have  to 
be  enjoined.  The  fat  chlorotics  may  be 
allowed  as  much  as  4  ounces  of  albumin 
per  diem,  and,  in  addition,  no  more  fat 
and  carbohydrates  than  will  cause  the 
nutritive  value  of  the  food  to  exceed  18 
calories  per  pound  of  body-weight.  Carl 
von  Noorden  (Inter.  Med.  Mag.,  May, 
'94). 

Milk  sliould  be  used,  or,  if  this  is  badly 
borne,  pure  water  or  a  hot,  weak  infusion 
of  tea  (hot  drinks  excite  the  gastric  se- 
cretion), eggs,  jiur/:n  of  vegetables,  lean 
fish,  fowl,  and  cooked  fruits.  One-half 
hour  before  the  meal  a  small  dose  of  an 
alkali,  as  sodium  bicarbonate,  7  %  grains, 
Hhould  be  prescribed  for  the  purpose  of 
exciting  the   flow  of  gastric  juice.     At 


the  same  interval  after  it  a  Madeira  glass 
of  hydrochloric  acid  in  solution  in  water, 
1  to  250.  The  hydrochloric  may  be  re- 
placed by  lactic  acid,  1  or  2  grammes  (15 
or  30  grains)  after  meals.  It  is  necessary 
to  forbid  the  use  of  wines,  cinchona- 
wine,  strong  beers,  alcoholic  drinks  and 
stimulating  food.  If  there  are  gaseous 
formations,  lavage,  either  of  pui-e  water 
or  water  containing  salicylic  acid,  1  per 
1000,  is  indicated.  After  two  to  four 
weeks  of  this  treatment  the  use  of  the 
preparations  of  iron  can  be  begun.  Henri 
Huchard  (Kevue  G6n.  de  Clin,  et  de 
Th6r.  Jour,  des  Prat.,  Jan.  19,  '95). 

Kest  in  bed,  when  sufficiently  pro- 
longed, is  of  the  greatest  importance, 
checking  the  too  rapid  destruction  of  the 
red  globules.  The  choice  of  food  is  made 
subordinate  on  account  of  the  dyspepsia 
which  generally  accompanies  chlorosis. 
There  is  often  an  hyperpepsia  of  medium 
degree  and  some  dilatation.  In  such 
cases  the  food  at  first  should  consist  of 
milk  and  raw  meat ;  later  on,  of  un- 
der-done eggs,  the  easily  digested  vari- 
eties of  fish,  piirie  of  gi'een  vegetables, 
and  stewed  fish.  No  bread  is  allowed 
for  four  or  five  weeks.  In  about  20  per 
cent,  of  the  cases  the  gastropathic  state 
is  more  pronounced  and  needs  more  care. 
Sometimes  there  is  intense  parenchy- 
matous gastritis,  with  marked  dilata- 
tion; again,  there  may  be  a  gastritis 
which  has  caused  diminished  glandular 
secretion  and  an  liypopeptic  state.  In 
the  former  case,  in  addition  to  restricted 
diet,  massage  is  to  be  used,  and  lavage 
also,  when  abnormal  fermentation  exists. 
By  the  use  of  these  measures  it  is  gen- 
erally possible  to  begin  ferruginous 
treatment  in  from  two  to  four  weeks. 
In  liypopeptic  conditions,  however,  iron 
(either  Blaud's  pills  or  the  protoxalate) 
may  bo  used  from  the  first  before  meals 
and  hydrochloric  acid  a  half-hour  after 
eating.  Ilayem  (Le  Bull.  M6d.,  Apr.  21, 
'95). 

According  to  Dr.  Ilaig,  of  London, 
who  has  done  so  much  to  increase  our 
knowledge  of  lithasmic  conditions,  "iron 
cures  ana3mia  by  clearing  the  blood 
of  uric  acid."  When  iron  fails  to  cure 
chlorosis,  he  recommends  its  suspension 


CHLOROSIS.    TREATMENT. 


101 


and  the  administration  of  mercurials  and 
salicylates  until  the  blood  is  cleared  of 
uric  acid,  after  which  improvement  may 
occur,  without  the  resumption  of  iron. 

There  has  been  much  discussion  con- 
cerning the  modus  operandi  of  iron  in 
chlorosis.  A  study  of  a  few  cases,  per- 
haps even  of  one,  will  lead  the  reflecting 
physician  to  the  conclusion  that  the 
cause  of  chlorosis  is  not  a  deficient  sup- 
ply of  iron,  but  something  that  interferes 
with  its  assimilation.  Nearly  all  our 
food-substances  contain  iron,  and  there 
is  probably  no  drinking-water  in  which 
traces  of  it  cannot  be  found.  It  is  evi- 
dent, therefore,  that  there  is  something 
that  interferes  with  the  assimilation  of 
the  iron  which  is  abundantly  present  in 
the  food  of  chlorotic  persons. 

Until  quite  recently,  no  satisfactory 
explanation  could  be  given  of  the  effi- 
cacy of  iron  in  chlorosis  and  especially 
of  the  necessity  of  administering  it  in 
large  doses,  for  it  was  known  that  very 
little  of  the  drug  was  absorbed.  Nearly 
all  the  iron  given  by  the  mouth  can  be 
recovered  in  the  fajces,  and,  therefore, 
it  would  appear  that  a  large  portion  of 
the  drug  is  wasted  and  that  equally  good 
results  might  be  obtained  by  its  use  in 
small  doses.  This,  however,  is  not  the 
case,  and,  thanks  to  the  investigations  of 
Bunge,  we  have,  at  the  present  time,  at 
least  a  working-hypothesis  on  which  to 
base  our  employment  of  the  metal.  In 
the  first  place,  our  food,  which  contains 
all  the  iron  we  need,  does  not  contain  it 
in  inorganic  form,  but  in  an  exceedingly 
complex  organic  combination.  Now,  in 
chlorosis,  as  is  so  emphatically  insisted 
upon  by  Sir  Andrew  Clark,  digestive 
disturbances  are  exceedingly  common. 
Abnormal  fermentations  and  decompo- 
sitions take  place  in  the  gastro-intestinal 
tract  which  give  rise  to  the  formation  of 
quantities  of  sulphides.     These  decom- 


pose the  iron  contained  in  the  food  and 
completely  unfit  it  for  the  purposes  of 
nutrition.  By  administering  an  inor- 
ganic preparation  of  iron  we  protect  the 
organic  combinations  of  that  metal  in 
the  food,  for  the  sulphur  in  the  intestine 
combines  with  the  iron  administered, 
and  allows  that  normally  contained  in 
the  food  to  be  absorbed.  This  theor}'  of 
Bunge  also  explains  why  it  is  sometimes 
necessary  to  administer  colossal  doses  of 
iron,  for,  in  such  cases,  the  decomposi- 
tions in  the  intestine  are  usually  active, 
sulphur  is  fonned  in  large  quantity  and 
requires  a  proportionally  large  amount 
of  iron  to  take  it  up. 

It  is  only  proper  to  add  that  Bunge's 
theory  has  lately  been  contested  by 
Ealph  Stockman,  of  Edinburgh,  who 
claims  to  have  cured  cases  of  chlorosis 
with  sulphite  of  iron,  and  who  contends 
that  bismuth,  manganese,  and  other 
drugs  which  are  just  as  capable  of 
absorbing  sulphuretted  hydrogen  as  is 
iron,  are  inert  in  chlorosis.  Stockman, 
nevertheless,  acknowledges  that  the 
promptest  curative  effects  are  obtained 
with  inorganic  preparations  of  iron. 

There  has  been  a  great  deal  of  dis- 
cussion concerning  the  relative  merits 
of  organic  and  inorganic  preparations  of 
iron,  and  there  can  be  little  doubt  that 
both  are  effective.  The  protoxalate  is 
a  favorite  preparation  of  certain  emi- 
nent French  practitioners,  while  others 
claim  that  the  best  results  are  obtained 
with  the  sulphate,  either  alone  or  com- 
bined with  potassium  carbonate,  as  in 
the  well-knovrn  pill  of  Bland.  For  my 
own  part,  I  am  accustomed  to  place  the 
most  reliance  on  the  inorganic  salts  of 
iron,  although  I  have  obtained  good  re- 
sults with  both  the  malate  and  the  lac- 
tate. So  far  as  iron  is  concerned,  the 
efforts  of  pharmacists  seem,  of  late,  to 
be   directed   toward   the   production    of 


103 


CHLOROSIS.    TREATMENT. 


preparations  which  resemble  the  organic 
iron  compounds  of  the  food.  This  seems 
a  misdirection  of  endeavor,  for  it  is  just 
this  iron  of  the  food  which  is  not  assim- 
ilated by  chlorotics. 

All  preparations  of  iron  do  not  act 
identically.  They  may  be  divided  into 
five  groups:  (1)  the  ferrocyanides,  which 
have  no  action;  (2)  the  blood  from  an 
organism  of  the  same  species,  which  may 
be  useful  during  a  certain  period;  (3) 
haemoglobin  in  solution,  which  probably 
penetrates  rapidly  into  the  circulation 
and  is  assimilated;  (4)  the  ferruginous 
salts  of  vegetable  acids,  which,  at  least 
by  subcutaneous  injection,  are  taken  up 
by  the  circulation,  and  deposited  in  the 
liver;  (5)  insoluble  preparations  and  fer- 
ric-oxide salts,  which  dissolve  in  the 
stomach  and  later  form  albuminates  and 
absorbable  iron.  Blaud's  pills  and  acid 
lactate  of  iron  have  seemed  to  be  the 
most  active  in  chlorosis.  A  daily  dose 
of  1  to  1  V»  grains  is  sufficient.  For 
hypodermic  injection  a  5-per-cent.  solu- 
tion of  ferric  citrate  may  be  used,  a 
quantity  containing  from  1  to  1 '/,  grains 
being  injected  daily.  Quincke  (LaPresse 
M6d.,  Apr.  10,  '95). 

Results  of  treatment  by  inhalation  of 
oxygen-gas  at  half  the  atmospheric  pres- 
sure in  three  cases  of  chlorosis  in  women, 
all  of  whom  had  previously  been  treated 
with  iron,  and  one  of  them  with  arsenic 
as  well.  In  one  case  there  were  signs  of 
phthisis.  Oxygen  inhalations  were  given 
three  times  daily  with  marked  improve- 
ment. Iron  is  not  indicated  in  cases 
where  there  is  nervous  excitement  or 
where  digestion  is  impaired.  Such  cases 
do  better  under  arsenic  combined  with 
oxygen  inhalations  diluted  with  nitro- 
gen. Corish  (N.  Y.  Med.  Jour.,  Feb.  13, 
'97). 

Under  the  influence  of  iron  adminis- 
tered hypodermieally  menstruation  is  re- 
establiHhcd,  and  this  efTect  is  dependent 
upon  the  general  improvement  of  the 
organism  and  the  excitant  action  or 
hypcraimia  induced  liy  the  drug.  Under 
the  injection  of  manganese  tlie  reappear- 
ance of  the  mcnBcs  is  more  tardy,  al- 
though the  general  health  is  much  im- 


proved. The  reappearance  of  menstrua- 
tion is  always  followed  by  an  improve- 
ment in  the  general  health  and  in  the 
blood.  Iron  and  manganese  act  espe- 
cially as  reconstituents,  not  exclusively 
upon  the  hsemoglobin,  but  also  upon  the 
red  cells.  Arsenic  does  not  materially 
increase  the  hfemoglobin,  but  it  notably 
increases  the  number  of  red  cells.  Stefl'a- 
nelli  (Settiniana  Med.,  Xos.  40  and  41, 
'99). 

Hasmalbumin  recommended  for  the  re- 
lief of  chlorosis.  It  is  a  powder  readily 
soluble  in  hot  water  or  alcohol,  and  con- 
tains all  the  salts  and  albumins  present 
in  the  blood.  Dose  of  hfemalbumin  is  15 
grains  three  times  a  day.  Goliner 
(Deutsche  med.-Zeit.;  Med.  News,  Apr. 
15,  '99). 

Sanguinal  recommended  very  highly 
in  the  treatment  of  anremia  and  chloro- 
sis. Sanguinal  contains  10  parts  of 
chemically-pure  ha;nioglobin,  46  parts  of 
the  normal  blood-salts  of  the  human 
blood,  and  44  parts  of  muscle-albumin. 
Each  pill  represents  about  75  grains  of 
fresh  blood.  Victor  Reichsberg  (Deut- 
sche med.-Zeit.,  May  21,  1900). 

In  conclusion,  I  will  describe  the 
method  of  treatment  so  strongly  advo- 
cated by  Sir  Andrew  Clark.  With  care- 
ful attention  to  the  diet  and  a  tepid 
sponge  bath,  followed  by  brisk  toweling 
night  and  morning,  he  prescribes  the 
following  mixtvtre: — 

]^  Ferri  sulphatis,  gr.  xxiv. 

Magnes.  sulphatis,  3vj. 

Acid,  sulph.  aromat.,  5j. 

Tinct.  zingib.,  oij. 

Ini'us.  gentian  comp.  vel  quassiaj, 

oviij- 
M.    Sig.:   One-sixth  part  twice  daily, 
about  11  and  6  o'clock. 

Occasionally  this  acid  mixture  pro- 
duces sickness,  dries  the  skin,  and  is 
otherwise  ill  borne.  In  such  cases  he 
prescribes  the  following  alkaline  mixt- 
ure:— 


CHLOROSIS.     TREATMENT. 


103 


]^  Ferri  sulphatis,  gr.  xxiv. 

Sodii  bicarb.,  oij. 

Sodii  sulphatis,  5vj. 

Tinct.  zingib.,  3ij. 

Spt.  chloroformi,  oj. 

Infus.  quassijE,  o'^iij- 
M.  Sig.:  One-sixth  part  twice  daily, 
at  11  and  6  o'clock.  Sometimes  neither 
mixture  agrees  with  the  patient,  in 
which  he  prescribes  sulphate  of  iron  in 
pill  with  meals  and  a  saline  aperient  on 
first  waking  in  the  morning.  By  this 
plan  Clark  claims  that  nine  out  of  ten 
cases  recover  in  from  one  to  three 
months,  and  by  careful  attention  to  the 
bowels,  taking  twice  a  week  a  pill  com- 
posed of  aloes,  myrrh,  and  iron,  the  re- 
covery will  probably  be  permanent. 

Summary  showing  the  average  gain  in 
heemoglobin  per  week  from  the  use  of 
various  agents:  Betanaphthol,  2  grains 
three  times  daily  (antisepsis),  30  cases, 
1.85  per  cent.;  Blaud's  iron  pills,  5 
grains  three  times  a  day,  31  cases,  5.07 
per  cent.;  cathartics  alone,  7  cases,  lost 
1.50  per  cent.  Twelve  cases  treated  with 
Blaud's  pills  after  a  course  of  betanaph- 
thol showed  an  average  weekly  increase 
of  G.70  per  cent.;  19  cases  treated  with 
Blaud's  pills  without  betanaphthol 
showed  an  increase  of  but  4.50  per  cent. 
Series  of  28  cases  treated  during  an  aver- 
age period  of  4.3  weeks,  with  2  grains 
of  betanaphthol,  in  tablet  form,  and  5 
grains  of  Blaud's  iron  pills  three  times  a 
day.  The  average  gain  in  hoemoglobin 
per  week  was  7.9  per  cent.,  the  maxi- 
mum gain  being  20  per  cent,  per  week 
for  2  weeks  in  one  case,  14  per  cent,  for 
3  weeks  in  another,  13  per  cent,  for  4 
weeks  in  another,  while  another  patient 
averaged  a  gain  of  11.4  per  cent,  per 
week  for  5  weeks.  The  average  amount 
of  hsemoglobin  possessed  by  the  patients 
before  beginning  the  treatn\ent  was  48 
per  cent.  After  4.3  weeks  of  treatment 
it  was  82  per  cent.  Conclusion  that  the 
results  of  combined  treatment  are  con- 
siderably better  than  those  obtained  "'■'•h 
iron  alone,  and  much  better  than  tiiose 
obtained  with  betanaphthol  alone.  Town- 


send  (Boston  Med.  and  Surg.  Jour.,  May 
27,  "96). 

Chlorotic  cases  can  be  divided  into 
three  classes:  Those  in  which  iron  is 
absolutely  useless,  those  in  which  it  is 
fairly  valuable,  and  those  in  which  it  is 
an  absolute  necessity.  The  cases  in 
which  it  is  useless  are  those  which  have 
been  deprived  of  fresh  air  and  sunshine, 
and  only  need  proper  food  and  outdoor 
life,  with  stimulant  treatment,  to  regain 
their  health.  Those  in  which  it  is  moder- 
ately valuable  are  the  pseudochlorotics 
who  have  as  an  underlying  cause  a  tend- 
ency to  develop  tuberculosis  with  gen- 
eral debility;  but,  as  a  rule,  the  more 
dyspeptic  tlie  patient,  the  less  good  will 
iron  do.  The  cases  in  which  the  iron  is 
most  useful  are  those  in  which  the 
patients  are  devoid  of  dyspeptic  symp- 
toms, when  any  one  of  the  common  iron 
preparations  may  be  given  in  large  or 
small  doses  with  advantage.  Should 
there  be  a  syphilitic  dyscrasia  underlying 
the  ansemia,  mercurials  should  be  admin- 
istered in  addition  to  the  iron,  preferably 
the  bichloride  of  mercury.  Huchard 
(Revue  de  Ther.  Medico-Chir.;  Ther. 
Gaz.,  Sept.   15,  '97). 

In  cases  in  which  there  is  an  accelera- 
tion of  the  heart-beats  recourse  has  been 
had  to  medicaments,  diminishing  the  ap- 
parent action  of  the  heart,  such  as  digi- 
talis. These  therapeutic  agents  have  very 
little  success  in  such  cases,  their  action 
being  only  temporary;  so  that  the  palpi- 
tations recur;  while  for  some  patients 
digitalis  is  even  hurtful.  Dependence 
should,  hence,  not  be  placed  upon  these 
agents,  but  rather  upon  those  acting  upon 
the  nervous  system,  as  bromide  of  sodium, 
valerian,  camphor,  etc.     (Potain.) 

The  salts  of  copper  are  especially 
valuable  in  chlorotics  with  cervical 
lymphadenitis.  Cases  without  tubercu- 
losis do  best  under  iron  or  arsenic.  But 
scrofulo-tuberculous  cases  are  most 
benefited  by  phosphate  of  copper.  Men- 
(lini  (Jour,  des  Praticiens,  Apr.  27, 
1901). 

The  practice  of  Mendini  in  employing 
copper  salts  in   chlorosis,   amenorrhoea. 


104 


CHOLELITHIASIS.    PHYSICAL  PROPERTIES.    CLASSIFICATION. 


and  cervical  lymphadenitis  recommended. 
The  acetophosphate  is  preferred,  and  in 
many    of   the   eases   imder   observation 
for  the  past  twenty-five  years  marked 
improvement  in  the  blood  condition  has 
resulted.     E.  Li^geois   (Jour,  des  Prati- 
ciens,  vol.  sv,  p.  225,  1901). 
Bone-marrow     and     ovarian     extract 
have  been  employed  with  some  success 
in  the  treatment  of  chlorosis,  but  their 
value  has  not,  as  yet,  been  suificiently 
established  to  warrant  more  than  an  en- 
couragement for  further  trial. 

Ovarian  substance  tried  in  several 
cases.  After  the  first  treatment  the  pa- 
tients complained  of  pain  in  the  lower 
abdomen,  discomfort,  headache,  and  mus- 
cular pain.  Two  had  fever  and  rapid 
pulse.  In  three  patients  the  result  was 
good.  The  general  health  was  improved, 
the  ancemia  disappeared,  the  number  of 
blood-corpuscles  was  increased,  and  the 
menses  returned.  Spillmann  and  Etienne 
(Gaz.  M6d.  de  Paris,  No.  35,  '96). 
Fhederick  p.  Henry, 

Philadelphia. 

CHOLELITHIASIS.  — From  Gr., 
xoX>7,  bile,  and  /udiaaig,  from  /{.Wog,  a 
stone. 

Definition. — The  term  "cholelithiasis" 
is  applied  to  that  condition  which  re- 
sults from  the  precipitation  of  clioles- 
terin  from  bile  and  from  the  combina- 
tion of  bilirubin  and  lime,  which  form 
an  insoluble  compound.  Tliese  two  make 
up  nearly  the  whole  mass  of  the  biliary 
calculi.  The  calculi  are  of  varying  size 
and  density. 

The  presence  of  concretions  in  tlie 
biliary  passages  may  produce  obstruction 
of  the  ducts,  ulceration  and  perforation 
of  the  walls,  and  the  formation  of  fis- 
tulous channels.  The  process  may  be 
accompanied  by  cholangitis,  cholecys- 
titis, and  perihepatic  abscess.  Obstruc- 
tive jaundice,  biliary  cirrliosis,  and  in- 
testinal obstruction  may  be  directly 
caused  by  gall-stones,  and  can  be  dis- 
cussed under  the  head  of  "cholelithiasis." 


Physical  Properties  ;  Varieties. — Bil- 
iary calculi  vary  in  size  from  that  of  a 
grain  of  sand  to  that  of  an  English 
walnut  or  be  even  larger. 

Case  in  which  a  conglomeration  of  cal- 
culi formed  a  mass  about  the  size  and 
shape  of  a  pear,  which  was  passed  during 
life.  The  patient  was  a  female,  60  years 
of  age.  Case  also  mentioned,  described 
by  Fiedler,  of  a  stone  consisting  of  three 
pieces  which  was  over  twelve  inches  in 
length  and  weighed  forty-sbc  grammes. 
It  completely  filled  the  gall-bladder. 
Krauss  (On  "Gall-stones,"  p.  11). 

The  smallest  (gall-sand)  are  dark  in 
color  and  are  wholly  made  up  of  bili- 
rubin-calcium.  Not  infrequently  a  large 
number  of  small  calculi,  angular,  fa- 
cetted, and  grayish  in  color,  are  found 
in  the  gall-bladder  or  in  a  sac  opening 
into  the  common  duct. 

The  larger  ones  are  dark  brown  or  of 
a  dark-yellowish  color,  depending  on  the 
amount  of  bilirubin-calcium  which  exists 
in  the  outer  layer. 

When  calculi  are  small  they  are  usu- 
ally very  numerous.  In  one  case  over 
two  thousand  were  removed. 

Case  of  choleeystotomy  performed 
by  Hatton  in  which  440  gall-stones  were 
removed  from  a  woman,  43  years  of 
age,  who  stated  that  until  five  weeks 
before  the  operation  slie  was  quite 
well,  but  at  this  time  slie  was  seized 
witli  an  attack  of  hepatic  colic.  Rid- 
oiit  (Lancet,  Foli.  14,  1003). 

The  larger  ones  exist  singly  or  in 
small  numbers.  The  shape  depends  on 
the  number  present.  WJicn  large  and 
single  they  are  round  or  more  frequently 
oval,  but  when  a  number  exist  together 
in  the  gall-bladder  or  in  a  sacculated 
enlargement  of  the  bile-duct  they  are 
facetted,  the  result  of  attrition.  Occa- 
sionally a  single  stone  is  found  facetted: 
an  indication  that  others  have  already 
passed  tlirough  the  ducts. 

Classification.  —  Biliary   calculi    have 


CHOLELITHIASIS.    SYilPTOlIS. 


105 


been  classified  according  to  the  propor- 
tionate amount  of  their  two  principal 
constituents:  cholesterin  and  bilirubin- 
calcium.  They  may  be  divided  into 
three  principal  classes: — 

1.  Pure  cholesterin. 

2.  Mixed  cholesterin  and  bilirubin- 
calcium. 

3.  Pure  bilirubin-calcium. 

The  mixed  variety  is  altogether  the 
most  frequently  met  with,  and  choles- 
terin is  the  principal  constituent. 

Naunyn,  whose  classification  is  now 
generally  adopted,  makes  the  following 
division: — 

1.  Pure  cholesterin. 

2.  Laminated  cholesterin. 

3.  The   common   gall-bladder   stones. 

4.  Mixed  bilirubin-calcium. 

5.  Pure  bilirubin-calcium. 

6.  Earer  forms. 

The  common  gall-bladder  stones  are 
altogether  the  most  frequent.  The 
larger  ones  are  about  the  size  of  a  cherry, 
and  they  may  be  of  a  lemon  or  brownish- 
yellow  color.  When  fractured,  the  sur- 
face presents  a  crystalline,  glistening  ap- 
pearance, in  which  the  light-yellowish 
color  predominates.  The  cholesterin  is 
arranged  in  layers  between  which  bili- 
rubin-calcium exists  in  greater  or  less 
quantities.  The  nucleus  is  often  com- 
posed of  bilirubin-calcium;  broken-down 
epithelial  cells,  bacteria,  and  foreign 
bodies  have  been  found  in  the  centre. 
When  very  numerous,  calculi  in  the  gall- 
bladder are  often  of  a  light-grayish 
color,  and  consist  of  an  outer  shell  and 
a  soft  nucleus. 

The  pigmentary,  or  bilirubin-calcium 
calculi  gall-sand,  are  small,  and  uce 
found  in  greater  numbers  than  the 
cholesterin  and  mixed  varieties.  They 
are  sometimes  found  in  the  intrahepatic 
ducts,  and  appear  to  be  the  result  of 
a  catarrhal  cholangitis.     A  rare  variety 


of  gall-stones,  composed  principally  of 
calcium  carbonate,  is  occasionally  found. 

Besides  the  constituents  already  men- 
tioned, the  following  elements  and  com- 
pounds have  occasionally  been  noted: 
Calcium  sulphate  and  phosphate;  cop- 
per and  iron  combined  with  bilirubin- 
calcium.  Globules  of  mercury  were 
found  by  Ferrictis. 

Symptoms. — The  symptoms  of  gall- 
stones may  be  studied  under  three  heads: 
1.  Those  produced  by  the  passage  of 
calculi  through  the  natural  channels.  2. 
Those  produced  by  gall-stones  when 
they  have  found  their  way  outside  of  the 
gall-bladder  and  ducts.  3.  Complica- 
tions and  sequelae. 

Passage  of  Gall-stones  Through 
THE  Natural  Channels. — Gall-stones 
may  remain  for  years  in  the  gall-bladder 
without  producing  any  marked  symp- 
toms, although  bile-pigment  may  be 
found  in  small  quantities  in  the  urine. 
It  may,  as  Dr.  Adler  has  pointed 
out,  pass  into  the  circulation  through 
the  base  of  the  ulcer.  It  is  said  that  the 
presence  of  calculi  can  be  made  out  by 
palpation  and  percussion,  but  sounding 
for  gall-stones  through  the  abdominal 
walls  is  now  almost  universally  con- 
demned as  being  more  dangerous  than 
a  laparotomy. 

Krauss  recently  described  a  prodromal 
state  of  cholelithiasis.  The  symptoms, 
more  marked  in  females,  are  constipa- 
tion, flatulency,  loss  of  appetite,  and  a 
sense  of  pressure  in  the  epigastrium. 
The  skin  of  the  face  first  becomes  pale 
and  yellowish,  then  j'ellowish  b^o^vn. 
The  lower  portion  of  the  conjunctiva  is 
tinged  yellow.  The  urine  is  scanty  and 
with  excess  of  uric  acid.  Bile-pigment, 
which  is  at  first  absent  from  the  urine, 
afterward  appears  in  small  quantities. 
Bilious  headaches  and  migraine  are  im- 
portant symptoms. 


106 


CHOLELITHIASIS.    SYMPTOMS. 


When  a  gall-stone  escapes  from  the 
gall-bladder,  it  is  \isually  arrested  for 
a  time  in  the  cystic  duct  on  account  of 
its  narrowness  and  of  the  structure  of 
Heisters  valve.  In  the  common  duet 
a  calculus  may  be  arrested  in  any  part 
of  its  course,  most  frequently  near  the 
duodenal   extremitv.     In   the  first  case 


The  cut  edges  of  the  duodenum  are  stitched 
together,  leaving  a  portion  of  the  mucous 
membrane  e.xpo.sed.  A  gall-stone  pro- 
trudes partly  through  the  duodenal  open- 
ing of  the  common  bile-duct.      {Andcmon.) 

biliary  colic  without  jaundice  is  usually 
present,  and  in  the  latter  colic  with 
jaundice.  It  must,  however,  be  remem- 
bered that  a  calculus  may  pass  through 
into  the  duodenum  without  pain  or  any 
other  disturbance.  This  usually  hap- 
pens when  the  ducts  have  been  widened 
by  the  passage  of  stones  previously. 
Biliary    Colic.  —  Premonitory    symp- 


toms— such  as  those  of  dyspepsia,  a  feel- 
ing of  weight  and  distress  with  great 
restlessness — may  be  present.  The  onset 
is  usually  sudden:  a  severe  paroxysmal 
pain  is  e.xperienced  in  the  gall-bladder 
region,  radiating  upward  to  the  right  or 
left  shoulder,  across  or  down  the  ab- 
domen to  the  thighs.  The  pain  is  parox- 
ysmal and  increases  in  severity  until  it 
reaches  a  climax.  The  patient  becomes 
more  and  more  restless,  tossing  upon 
the  bed  or  throwing  himself  from  the 
bed  to  the  floor,  rolling  about  in  agony. 
When  the  suffering  reaches  its  height, 
vomiting  may  occur,  which  may  in  turn, 
be  followed  by  sudden  relief.  Intervals 
of  comparative  ease  may  follow  parox- 
ysms of  pain,  and  this  may  continue  for 
hours  and  even  days. 

[Dr.  H.  B.  Anderson,  of  Toronto,  wit- 
nessed the  case  (unpublished)  of  a 
woman,  aged  50,  who  died  after  six 
months'  illness.  Had  deep  jaundice 
throughout;  also  pruritus,  with,  latterly, 
chills,  fever,  and  purpura.  Suffered  no 
pain.  Had  previous  attacks  of  cholelith- 
iasis with  great  pain,  but  no  marked 
jaundice. 

Autopsy  showed  well-marked  catarrhal 
cholangitis.  Gall-bladder  thickened,  dis- 
torted, and  atrophied,  and  contained  a 
small  quantity  of  bile.  Common  duct 
greatly  dilated,  bad  conical-shaped  cal- 
culus impacted  at  and  partly  protruding 
through  th3  duodenal  opening.  (See 
wood-cut.) 

On  bacteriological  examination,  the 
colon  bacillus  was  found  in  the  blood, 
spleen,  and  liver.     J.  E.  GnAilAM.] 

The  vomiting  already  mentioned  oc- 
curs toward  the  end  of  the  seizure,  in 
a  large  number  of  cases.    The  contents 
of  the  stomach  are  first  expelled,  and 
bile  follows.    In  some  instances  the  vom- 
iting may  be  continuous  and  persistent, 
and  may  itself  be  a  dangerous  symi)tom. 
Two  cases  of  persistent  vomiting  from 
calculi  in  the  ducts,  upon  which  opera- 
tion was  performed.    In  one  the  vomiting 


CHOLELITHIASIS.    SYMPTOMS. 


107 


continued  for  days  after  the  cause  had 
been  removed.  The  patient,  however, 
made  a  good  recovery.  In  the  second 
the  emesis  had  been  so  persistent  that 
the  patient  liad  to  be  sustained  by  nu- 
tritious enemata  for  four  weeks  previous 
to  the  operation.  Afterward  the  vomit- 
ing continued  for  two  weeks,  when  death 
took  place  from  exhaustion.  Mayo  Rob- 
son   (Allbutt's  "System  of  Medicine"). 

The  severity  of  the  collapse  varies  in 
different  cases.  It  is  marked  by  cold, 
clammy  skin,  pallor,  and  weakness  and 
frequency  of  the  pulse.  It  has,  in  some 
instances,  proved  fatal.  Potain  men- 
tions acute  dilatation  of  the  right  heart 
as  sometimes  taking  place  in  biliary 
colic. 

Case  of  a  woman,  aged  47  years,  who 
died  suddenly  in  collapse,  preceded  by 
agonizing  pain,  while  under  treatment 
for  hepatic  colic.  There  was  found  in 
the  abdomen  a  blood-clot  weighing  GOO 
grammes  (20  ounces),  and  some  san- 
guinolent  liquid.  Pauly  (Lyon  M6d., 
Jan.  24,  '92). 

Report  of  a  cise  from  heart-failure  dur- 
ing an  attack  of  biliary  colic  in  a  dia- 
betic patient.  Changes  in  the  myocar- 
dium were  found  at  the  autopsy.  Eisner 
(Med.  News,  Feb.  5,  '98). 

The  presence  of  a  tumor  below  the 
costal  line  indicates  dilatation  of  the 
gall-bladder,  which  takes  place  in  early 
attacks.  A  distended  gall-bladder  may 
occasionally  e.xist  in  more  or  less  chronic 
biliary  lithiasis  as  a  result  of  impaction 
of  the  cystic  and  common  ducts.  It  is, 
however,  more  frequently  found  in  cases 
of  malignant  disease.  Enlargement  of 
the  spleen  is  present  in  some  febrile 
cases. 

Hepatic  colic  may  also  be  due  to  a 
simple  spasm.  1.  Clinical  proofs:  hepatic 
colic  is  common  in  cases  of  hysteria, 
where  no  gall-stone  is  present.  2.  Proofs 
from  pathological  anatomy:  cases  have 
been  observed  of  jaundice  and  colics  in 
which  the  only  lesion  found  was  contrac- 
tion of  the  bile-duct.     3.  Experimental 


proofs:  spasm  of  the  lower  part  of  the 
common  duct  can  be  set  up  in  dogs. 
Lepine  (Lyon  M6d.,  Feb.  18,  '94). 

At  the  commencement  of  an  attack  of 
cholelithiasis — i.e.,  at  a  time  when  pain 
has  not  set  in — a  tumor  represented  by 
the  gall-bladder  is  tangible.  This  disap- 
pears directly  the  gall-stone  reaches  the 
intestine.  Not  infrequently  the  pains 
do  not  at  once  subside;  these  may  be 
caused  b\-  slight  circumscribed  local  peri- 
tonitis in  the  region  of  the  gall-bladder, 
and  may  be  lessened  by  ice-cold  com- 
presses. Swelling  of  the  gall-bladder 
may  also  be  caused,  however,  by  occlu- 
sion of  the  common  duct  by  ascarides, 
Distoiiia  hepaticum,  or  inflammatory  ex- 
udations and  by  a  tumor  of  the  head  of 
the  pancreas  pressing  on  the  gall-duct. 
Gerhardt  (Deut.  med.  Woch.,  Oct.  15, 
'93). 

Catarrhal  jaundice;  cancer  of  the 
pancreas,  gall-bladder,  or  ducts;  cancer 
or  tuberculosis  of  the  liver,  malaria,  or 
cardiac  disease  may  give  rise  to  symp- 
toms simulating  those  of  stone  in  the 
common  duct.  G.  W.  Webster  (Jour. 
Amer.  Med.  Assoc,  June  22,  '95). 

Possibility  of  confusion  between  a  dis- 
tended gall-bladder  and  movable  kidney. 
To  distinguish  between  the  two  condi- 
tions it  must  be  remembered  that  a  dis- 
tended gall-bladder,  as  well  as  the  kid- 
ney, is  a  frequent  cause  of  movable  ab- 
dominal tumor.  The  range  of  motion 
in  the  gall-bladder  is,  however,  always 
in  the  are  of  a  circle,  the  centre  of  which 
is  a  point  beneath  the  right  lobe  of  the 
liver.  The  history  of  a  distinct  attack  of 
jaundice  is  an  important  factor  in  diag- 
nosis. A  distended  gall-bladder  can  gen- 
erally be  felt,  whereas  a  movable  kidney 
often  cannot.  The  gall-bladder,  if  dis- 
tended with  stones,  is  much  harder  than 
the  kidney.  Henry  Morris  (Brit.  Med. 
Jour.,  Feb.  2,  '95). 

In  cases  of  gall-stones  in  which  biliary 
colic  is  not  present  diagnosis  is  usually 
not  made  till  the  autopsy.  Dull  pain  in 
the  region  of  the  liver  and  vomiting 
noted  in  several  cases.  The  gallbladder 
is  not  usually  palpable;  it  could  be  felt 
in  one  of  the  cases  described,  but  not  in 
the  others.  A.  L.  Benedict  (Med.  News, 
June  S,  '95). 


108 


CHOLELITHIASIS.    SYMPTOMS. 


Kraiiss,  who  was  himself  a  sufferer 
from  biliary  colic,  gives  the  following 
chief  SYmptoms: — 

1.  Sudden  onset  between  two  and 
three  hours  after  a  meal. 

2.  Violent,  spasmodic,  paroxysmal 
pains  over  the  hepatic  and  epigastric  re- 
gion radiating  upward  over  the  right 
half  of  the  thorax. 

3.  Labored  respiration,  feeling  of  dis- 
tress, nausea,  and  vomiting. 

4.  Slow,  hard  pulse  and  cold  extremi- 
ties. 

5.  Sudden  or  gradual  termination  of 
the  attack. 

6.  Onset  of  jaundice,  which  under 
certain  circumstances  follows  the  attack. 

The  amount  of  pain  does  not  depend 
so  much  upon  the  size  of  the  stone  as 
upon  its  shape.  A  small  calculus  with 
sharp  projections  will  cause  more  pain 
than  a  much  larger  one  which  is  round 
or  oval. 

When  the  stone  is  arrested  in  the 
common  bile-duct,  similar  symptoms  to 
those  already  described  manifest  them- 
selves, together  with  jaundice.  It  is 
generally  thought  that  the  pain  is  not 
so  sharp  or  severe  when  the  calculus 
lodges  in  the  common  bile-duct  as  when 
it  is  arrested  in  the  cystic  duct. 

Icterus  ensues  a  day  or  two  after  the 
commencement  of  the  attack,  and  its 
intensity  will  depend  upon  the  amount  of 
obstruction.  Bile-pigment  may  be  found 
in  the  urine  before  any  change  is  no- 
ticed on  the  skin  or  conjunctiva.  In 
severe  cases  the  liver  may  be  slightly 
enlarged  and  tender  and  the  skin  of  a 
dark-yellow  color.  The  urine  is  dark 
and  the  faeces  clay-colored.  When  the 
obstruction  remains,  symptoms  of  a 
chronic  jaundice  are  observed,  accom- 
panied by  intense  itching  of  the  skin 
and  extravasations.     Want  of  appetite. 


foul  breath,  and  slow  pulse  are  symp- 
toms often  met  with. 

The  jaundice  of  cholelithiasis  is  gen- 
erally more  or  less  intermittent  in  char- 
acter, differing,  in  this  respect,  from 
that  of  cancerous  obstruction,  which  is 
usually  progressive.  Jaundice  may  con- 
tinue some  days  after  the  stone  is  ex- 
pelled, when  thickening  of  the  wall  may 
still  cause  obstruction. 

The  presence  of  bile-pigment  in  the 
blood  does  not  appear  to  cause  any  con- 
siderable disturbance  of  function  and  in 
any  ease  is  only  slightly  poisonous.  The 
bile-acids,  on  the  other  hand,  when  they 
enter  the  blood  act  as  virulent  poisons  on 
the  nervous  and  muscular  systems  and 
on  the  blood-corpuscles,  as  first  shown 
by  Dousche.  Thoma  ("Path,  and  Anat.," 
vol.  i,  p.  29). 

[This  statement  is  not  altogether  in 
accord  with  the  views  of  Bouchard,  who 
regarded  the  bile-pigment  vei^  poison- 
ous, and  who  ascribed  its  comparatively 
mild  effect  to  the  fact  that  it  is  either 
absorbed  by  the  tissues  or  rapidly  given 
ofT  by  the  kidneys.    J.  E.  Graham.] 

Gall-stone  attacks  are  frequently  ac- 
companied by  fever,  and  in  some  in- 
stances the  temperature  may  rise  to  104° 
F.  In  such  cases  there  is  usually  a 
rigor,  followed  by  great  heat  of  skin. 
The  sweating  stage  is  often  absent.  This 
has  been  called  hepatic-intermittent, 
and  is  probably  of  the  same  character  as 
that  which  sometimes  follows  the  pas- 
sage of  instruments  through  a  con- 
stricted urethra.  The  fever  is  thought 
to  he  reflex  by  some,  but  it  is  more  prob- 
ably the  result  of  toxin  absorption. 

The  length  of  time  required  for  the 
calculi  to  find  their  way  through  the 
cystic  and  common  duct  varies  in  differ- 
ent cases.  They  may  pass  through  so  rap- 
idly and  easily  that  obstructive  jaundice 
may  not  occur.  Again,  they  may  remain 
months  in  the  ducts  causing  very  fre- 
quently incomplete  obstruction.    This  is 


CHOLELITHIASIS.    SY.MPTOMS. 


109 


termed  by  some  the  irregular  form  of 
cholelithiasis. 

In  some  cases  the  calculus  floats  in  a 
distended  portion  of  the  duct,  usually 
the  ampulla  of  Vater,  causing  an  in- 
termittent or  remittent  jaundice. 

Fenger  agrees  with  Courvoisier  that 
gall-stones  in  the  common  duct  give  rise 
to  a  series  of  special  symptoms  by  which 
the  situation  can  often  be  diagnosed 
with  a  fair  amount  of  certainty.  Some 
of  these  symptoms  and  conditions  are: — 

1.  Atrophy  of  the  gall-bladder  and 
absence  of  tumor. 

2.  Presence  of  icterus,  which  may  be 
(a)  intermittent:  complete  freedom  from 
jaundice  when  the  calculus  passes  into 
the  duodenum,  (h)  Eemittent  jaundice 
is  usually  caused  by  a  floating  gall-stone 
acting  as  a  ball-valve. 

3.  Colic.  Localization  of  pain  out- 
side of  the  gall-bladder  region  indicates 
stones  in  the  common  duct.  Eemittent 
pain  is  the  sign  of  a  stone  floating  in  a 
dilated  portion  of  the  duct.  This  pain 
is  sometimes  relieved  by  change  of  posi- 
tion. 

4.  Intermittent  or  remittent  fever. 

Histories  of  a  number  of  cases.  In  one 
of  these  the  first  attack  of  colic  with 
icterus  had  occurred  two  years  before. 
These  attacks  then  became  more  and 
more  frequent  and  were  accompanied  by 
slight  remittent  icterus.  There  was  also 
remittent  pain  every  two  or  three  days 
for  three  weeks,  followed  by  fever,  ic- 
trni.i  prari.i,  and  death.  The  autopsy  re- 
vealed one  small  floating  stone  in  the 
dilated  common  duct. 

In  a  second  case  the  first  attack  of 
biliary  colic  had  taken  place  two  years 
previously,  followed  by  icterus.  Second 
attack  occurred  on  October  24th,  fol- 
lowed by  lighter  attacks,  loss  of  weight, 
slight  icterus,  but  no  tumor.  Operation 
of  choledochotomy.  One  stone,  two  cen- 
timetres in  diameter,  was  removed;  no 
leakage;  recovery.  The  patient  gained 
fifty  pounds  in  three  months.  Fenger 
(Amer.  Jour.  Med.  Sci.,  p.  286,  '97). 


Symptoms  of  a  gall-stone  in  the  am- 
pulla of  Vater  acting  as  a  ball-valve. 
Chronic  jaundice,  rarely  deep,  varying 
in  intensity,  at  times  almost  or  entirely 
disappearing,  to  deepen  invariably  after 
a  paroxysm  of  pain.  Often  a  constant 
sense  of  discomfort,  which  may  be  ago- 
nizing or  griping  or  like  an  ordinary 
liver-colic.  Fever  occurring  in  paro.\- 
ysms;  chills  may  be  quotidian  or  ter- 
tian in  type.  The  spleen  usually  enlarges 
with  the  febrile  paroxysms.  Although 
lasting  for  months  or  years,  the  health 
may  not  be  much  afltected,  the  patient 
being  able  to  work  between  the  parox- 
ysms. Such  cases  are  often  diagnosed 
as  chronic  malaria,  abscess  of  the  liver, 
or  suppurative  cholangitis.  Osier  (Lan- 
cet, May  15,  '97). 

Passage  of  Gall-stones  Ouxsiut 
THE  Ordinary  Channels. — The  symp- 
toms will  depend  upon  the  course  taken 
by  the  calculus.  In  some  instances  the 
stone  passes  through  the  ulcerated  wall, 
and,  owing  to  the  presence  of  pyogenic 
organisms,  an  abscess  forms,  which  gives 
rise  to  symptoms  similar  to  those  of  ap- 
pendicitis; pain,  high  temperature,  local- 
ized tenderness,  and  swelling.  The  ab- 
scess may  open  into  a  neighboring  cav- 
ity, most  frequently  at  the  intestines, 
or  it  may  extend  outwardly.  In  other 
cases  the  stone  may  form  a  fistula  witii 
very  few  localized  or  general  symptoms. 
Large  calculi  have  been  passed  by  pa- 
tients which  from  their  size  must  have 
made  their  way  by  ulceration  from  the 
gall-bladder  into  the  intestines,  although 
no  history  could  be  obtained  tending  to 
indicate  that  such  a  process  had  taken 
place.  As  a  rule,  however,  there  is  more 
or  less  local  pain,  tenderness,  and  swell- 
ing. 

The  broncho-biliary  fistula  is  accom- 
panied by  severe  coughing  and  the  ex- 
pectoration of  bile.  Gall-stones  have 
been  expectorated  in  some  cases.  I  have 
reported  a  case  in  which  expectoration 
of  bile  was  present  three  weeks  and  then 


no 


CHOLELITHIASIS.     COMPLICATIONS  AND  SEQUEL.E. 


ceased  to  retiirn;  after  ten  years'  time 
calculi  were  found  in  the  common  duct. 
Sudden  death  has  been  -^vitnessed  in  a 
case  in  which  rupture  took  place  into 
the  pericardium. 

Dilatation  of  the  stomach  due  to  in- 
flammatory  adhesions,   closing   the    py- 
lorus, or  to  the  presence  of  a  gall-stone 
making  its  way  through  the  pylorus  is 
attended  by  the  usual  symptoms  of  such 
a  condition.    Calculi  have  been  expelled 
from   the   stomach,   which   have    either 
found  their  way  into  that  viscus  directly, 
or,  as  is  more  commonly  the  case,  have 
been  regurgitated  from  the  duodenum. 
[The  following  case  presents  some  pe- 
culiar features:    The  patient  had  been 
under  the  ^VI-iter's  observation  for  many 
years    previous    to    his    death.      Fifteen 
years  before  he  suffered  from  biliary  colic 
and  obstructive  jaundice.     A  hard  mass 
remained,  which  was  thought  at  the  time 
to  be  cancer.    The  patient  recovered  and 
the  tumor  disappeared.     He  was  after- 
ward troubled  with  a  peculiar  form  of 
diarrhffia:     awakening   toward   morning 
he  had  two   or  three  watery   passages, 
which  weakened  him  very  much.    These 
attacks  toward  the  close  of  his  life  be- 
came more  frequent  and  were  very  dis- 
tressing.    The   cause   was    supposed    to 
be  want  of  tone  in  the  pylorus,  which 
allowed  undigested  food  to  pass  into  the 
bowel.     Very  little  of  the  latter,  how- 
ever, was  noticed  in  the  discharges.    The 
following  condition  was  found  at  the  au- 
topsy:   There  were  many  old  inflamma- 
tory adhesions  in  the  region  of  the  gall- 
bladder.   The  latter  was  much  contracted 
and  dislocated.     The  common  duct  was 
very  small. 

There  was  a  large  secular  dilatation 
of  the  duodenum,  which  formed  a  pouch 
four  inches  from  the  pylorus.  Tlie  pouch 
was  continuous  with  the  intestine  below 
by  a  valve-like  orifice  about  the  size  of 
the  pylorus.  This  was  probably  formed 
in  the  passage  of  the  gall-stones  fifteen 
years  before,  and  it  is  probable  that  the 
contents  of  the  stomach  accumulated  in 
the  poudi  and  were  at  times  discharged, 
producing  the   sudden   attacks   of   diar- 


rhoea. I  am  indebted  to  Drs.  Powell  and 
Anderson  for  the  post-mortem  notes.  J. 
E.  Graham.]  (Case  has  not  been  pub- 
lished.) 

The  arrest  of  calculi  in  the  intestines 
produces  at  once  a  series  of  very  grave 
sjTuptoms  of  gall-stone  ileus.  The  most 
prominent  are  sudden  and  severe  pain; 
nausea;  vomiting;  rapid,  quick  pulse; 
with  other  symptoms  of  collapse.  The 
mortality  in  such  cases  is  very  high.  The 
lower  part  of  the  jejunum  is  the  usual 
seat  of  the  obstruction.  When  the  stone 
is  arrested  in  the  duodenum,  the  gastric 
symptoms  are  much  more  marked,  and, 
when  in  the  lower  part  of  the  small  in- 
testine, indican  may  be  found  in  excess 
in  the  urine. 

Fatal  case  of  gall-stone  ileus.  The  pa- 
tient had  for  a  long  time  sufl'ered  from 
attacks  of  pain,  especially  when  tired 
from  standing.  At  the  operation  the 
stone  was  found,  after  a  long  search,  in 
the  small  intestine  and  removed.  It  was 
olive  shaped  and  weighed  400  grains. 
Death  from  collapse  took  place  two  days 
after  the  operation.  Bridon  (Annals  of 
Surg.,  Jan.,  '97). 

Case  in  which  a  tumor  e.\isted  in  the 
pyloric  region  fifteen  months  and  was 
generally  thought  to  be  a  cancer.  It  was 
afterward  shown  to  have  been  caused  by 
an  enormous  gall-stone,  which  ulcerated 
through  into  the  duodenum  and  brought 
on  symptoms  of  intestinal  obstruction. 
A  stone  (weighing  368  grains,  5  '/a  inches 
in  circumference,  and  3  inches  long) 
passed  with  some  difficulty  tln-ough  the 
rectum.  It  was  composed  almost  alto- 
gether of  cholesterin.  Eleven  months 
afterward  the  patient  passed  another 
stone  weighing  240  grains.  Eisner  (Med. 
News,  Feb.  5,  '98). 

Complications  and  Sequelae.  —  The 
most  frequent  complication  of  cholelith- 
iasis is  catarrhal  inflammation  of  the 
gall-bladder  and  ducts.  In  fact  this  oc- 
curs so  often  in  the  chronic  form  of  the 
disease  that  it  is  generally  regarded  as 
an  integral  part  of  it.     Thickening  of 


CHOLELITHIASIS.    COMPLICATIONS  AND  SEQUELAE. 


Ill 


the  walls  of  the  ducts  may  take  place 
to  a  sufficient  extent  to  produce  perma- 
nent obstruction  and  chronic  jaundice. 
Thickening  of  the  walls  and  contraction 
of  the  cavity  of  the  gall-bladder  result 
in  atrophy. 

Sometimes  the  process  ends  in  a 
fibrous  perihepatitis,  and  the  calculus 
will  be  found  imbedded  in  a  dense  mass 
of  connective  tissue.  These  attacks  are 
accompanied  by  more  or  less  pain  and 
tenderness  in  the  hepatic  region  and  by 
a  slight  -elevation  of  temperature. 

Acute  phlegmonous  inflammation  of 
the  gall-bladder  is  a  rare  disease.  Cour- 
voisier  described  it  under  the  term 
''Acute  Progressive  Empyema  of  the 
Gall-bladder,"  and  collected  notes  of 
seven  cases.  This  condition  may  exist 
when  gall-stones  are  not  present,  but  it 
is  usually  a  complication  of  cholelith- 
iasis. Typhoid  and  typhus  fevers,  ma- 
laria, and  septicsemia  are  the  usual  pri- 
mary diseases.  The  sjTnptoms  are  those 
of  a  low,  adynamic  fever,  rapid  and 
feeble  pulse,  great  depression,  with  ten- 
derness and  swelling  over  the  right  side 
of  the  abdomen.  As  a  rule,  general  peri- 
tonitis supervenes  and  death  takes  place. 
Occasionally  it  terminates  in  a  peri- 
hepatic abscess,  which  may  be  opened 
and  a  cure  effected. 

Pyogenic  organisms  may  invade  the 
gall-bladder  when  distended  on  account 
of  obstruction  in  the  cystic  or  common 
duct  and  give  rise  to  suppurative  chole- 
cystitis and  cholangitis.  The  patient 
experiences  pain  and  tenderness  in  the 
hepatic  region.  A  tumor  more  or  less 
tender  may  be  distinctly  palpated.  The 
general  symptoms  are  those  of  fever,  viz.: 
irregular  and  high  temperature,  rapid 
pulse,  and  great  loss  of  strength.  The 
symptoms  of  pya?mia  may  be  present, 
viz.:  rigors,  heats,  swellings,  loss  of 
appetite,   nausea,   vomiting,    and    great 


depression.  This  fever  must  be  distin- 
guished from  Charcot's  hepatic  inter- 
mittent, in  which  there  is  no  pus  present. 

Series  of  14  cases  illustrating  compli- 
cations arising  from  gall-stone  disease: 
1.  Impaction  of  stone  in  the  cystic  duct, 
followed  by  hydrops,  empyema,  and  cys- 
to-duodenal  fistula.     2.  Sloughing  of  the 
gall-bladder  and  formation  of  a   fistula 
between    it    and   the    stomach.     3.    Per- 
foration of  the  gall-bladder  and  forma- 
tion   of   a    fistula    between    it   and   the 
stomach.     4.  Impaction  of  stones  in  the 
hepatic   and   common   ducts.     5.   Impac- 
tion of  stones  in  the  common  duct.     6. 
Impaction  of  stones  in  the  ampulla  of 
Vater.     7.    Primary    carcinoma    of    the 
gall-bladder.     When   the   surgeon   opens 
the   abdomen   for   gall-stone   disease   he 
must  be  prepared  to  meet  and  deal  with 
any  complication,  and  complications  are 
met  in  from  20  to  30  per  cent,  of  all 
gall-stone  operations.    Jloynihan   (Brit. 
Med.  Jour.,  Nov.  S,  1902). 
Suppurative  cholangitis  presents  the 
same  general  symptoms,  but  no  tumor  is 
felt,  and  the  enlargement  of  the  liver  is 
more    marked.      Great    tenderness    may 
exist  over  the  hepatic  surface.  Persistent 
jaundice  is  a  constant  and  marked  symp- 
tom. 

As  described  by  Naunyn,  hepatic  ab- 
scess may  arise  from  cholelithiasis  in 
several  different  ways: — 

1.  An  empyema  of  the  gall-bladder 
may  burst  into  the  liver. 

2.  Purulent  cholangitis  of  the  intra- 
hepatic ducts  leads  to  ulceration,  which 
may  exist  in  different  places  in  the  liver. 

3.  The  hepatitis  sequestrans  of 
Schiippel. 

4.  Jletastasis  or  embolic  abscess. 
Ulcerative     endocarditis     may     arise 

from  infection  entering  the  circulation 
through  the  walls  of  the  gall-bladder  or 
ducts. 

Haemorrhage  is  a  complication  wliich 
may  occur  as  a  result  of  the  action  of 
biliary  toxins  on  the  blood.    Gastric  and 


112 


CHOLELITHIASIS.    DIAGNOSIS. 


intestinal  hsmorrhage  may  arise  from 
this  cause  or  from  ulceration  into  the 
blood-vessels.  Intestinal  hemorrhage 
may  also  be  caused  by  passive  conges- 
tion, the  result  of  thrombus  of  the  portal 
vein  due  to  the  pressure  of  biliary  cal- 
culi. Naunyn  has  not  observed  copious 
haemorrhages  from  this  cause. 

Perforation  of  the  gastric  or  intestinal 
mucous  membrane  is  an  occasional  cause 
of  haemorrhage.  The  writer  has  ob- 
served two  cases  in  which  he  concluded 
from  the  history  that  hasmorrhage  had 
arisen  in  this  way;  but  he  was  not  able 
to  verify  his  conclusions. 

In  Aufrecht's  case,  quoted  by  Naunyn, 
a  large  stone  had  partiallj'  broken 
through  from  the  gall-bladder  into  the 
hepatic  tissues;  this  led  to  severe  haemor- 
rhage, and  the  blood  had  entered  the 
gall-bearer  and  thence  had  flowed  into 
the  intestine  along  the  cystic  and  com- 
mon ducts.  Ulceration  of  the  portal 
vein  and  aneurism  of  the  hepatic  artery 
may  also  cause  fatal  haemorrhage. 

Diagnosis. — The  diagnosis  of  the  form 
of  biliary  colic  produced  by  the  arrest 
of  gall-stones  in  the  cystic  duct  is  often 
difficult.  The  unbearable,  cutting,  tear- 
ing, paroxysmal  pain  seated  in  the  gall- 
bladder region  and  radiating  to  the  right 
or  left  shoulder  is  an  important  char- 
acteristic. The  presence  of  a  tumor  in 
the  hepatic  region,  after  an  attack,  of 
the  characteristic  shape  of  a  distended 
gall-bearer  is  a  confirmatory  sign. 

Of  the  conditions  from  which  it  is 
to  be  differentiated,  the  most  frequent 
are:  neuralgia,  pleurisy,  gastric  colic, 
intestinal  colic,  and  appendicitis. 

Pleurisy. — The  presence  of  pleurisy 
may  be  made  out  by  careful  physical 
examination. 

NEunALGiA. — The  painful  points  of 
neuralgia  should  be  looked  for. 

Gastric  colic,  especially  that  form 


in  which  there  is  a  spasmodic  painful 
contraction  of  the  pylorus,  is  very  dif- 
ficult of  differentiation.  When  the  pains 
rapidly  follow,  for  instance,  the  taking 
of  cold  water  and  the  symptoms  are 
prominently  of  a  gastric  character,  the 
condition  may  be  recognized  as  one  per- 
taining to  the  stomach  and  not  to  the 
liver. 

Intestinal  Colic.  ■ —  In  intestinal 
colic  the  seat  of  pain  and  the  character 
of  the  latter  differ  from  those  of  biliary 
colic.  Chills  and  fever  accompany  bil- 
iary more  frequently  than  gastric  or  in- 
testinal colic. 

Acute  Appendicitis.  —  The  differ- 
entiation of  acute  appendicitis  is  some- 
times very  difficult,  especially  in  cases 
in  which  adhesions  to  the  under-surface 
of  the  liver  follow  an  attack.  Differ- 
ence in  the  seat  of  pain  in  first  attack 
is  nearly  always  marked. 

In  biliary  colic  the  pain  often  radiates 
upward  to  the  shoulder,  while  in  ap- 
pendicitis it  is  experienced  in  the  region 
of  the  umbilicus. 

In  the  writer's  experience,  it  is  of  the 
greatest  importance  to  note  down  ac- 
curately the  history  of  the  case  and  to 
observe  whether  the  symptoms  are  he- 
patic, renal,  or  intestinal. 

The  presence  of  gall-stones  in  the 
freces  is  the  crucial  test  in  the  diagnosis. 
These  may  escape  observation  unless 
great  care  is  taken  in  the  examination. 
The  stools  should  be  made  as  fluid  as 
possible  by  the  addition  of  water  and 
passed  through  a  fine  sieve. 

The  stools  slioiild  lie  passed  into  a 
double  paiize  bag.  The  bag  can  then 
be  allowed  to  hang  in  the  hopper  of 
the  water-closet  and  be  flushed  as  often 
as  necessary,  that  is,  until  all  the  solu- 
ble matter  has  l>oen  washcul  away. 
This  method  of  looking  for  gull-stones 
is  accurate  and  less  unpleasant  than 
(ilbors,  Tjili(!ni,lial  (Medical  Kecord, 
.Jan.  n,  1901). 


CJIOLIlLITHIA.SLS.     UIAUXUaiS. 


113 


The  prJiicij);!!  points  in  the  diagnosis 
of  chronic  cholelithiasis  are  the  attacks 
of  pain  more  or  less  severe  in  the  hepatic 
region,  tenderness  of  the  liver,  the  pres- 
ence of  a  tumor  resulting  from  periheji- 
atic  inflammation  or  abscess,  exacerba- 
tions of  fever  with  or  without  local  pain ; 
jaundice,  usually  intermittent  or  remit- 
tent; not  often  persistent  and  increasing. 

The  dilfercntiation  between  a  dis- 
tended gall-bladder  and  a  displaced 
right  kidney  is  often  difficult.  It  is 
not  infrequently  impossible  to  make  a 
distinction  by  noting  the  shape  and  size 
of  the  tumor;  occasionally  all  the  meth- 
ods generally  laid  down,  such  as  the 
movements  of  the  gall-bladder  by  respi- 
ration, the  limitation  of  its  movements, 
and  the  relative  situation  of  the  colon, 
are  all  of  little  use.  Sometimes  by  care- 
ful palpation  the  kidney  and  gall-bladder 
can  be  separated  and  a  positive  diagnosis 
made. 

Number  of  cases  in  which  gall-stone 
crepitus  was  made  out  and  proved  to  be 
of  great  diagnostic  value.  The  crepitus 
may  be  obtained  by  palpating  with  the 
finger-tips  dipped  gently,  but  deeply,  in 
the  abdominal  wall  just  below  the  fun- 
dus of  tlie  gallbladder  and  then  dra'svn 
upward  over  the  organ  as  though  mak- 
ing an  attempt  to  roll  the  fundus  up- 
ward and  forward.  Deep  inspiration  is 
helpful  and  the  tactile  sense  of  the  pal- 
pating fingers  may  be  increased  by  press- 
ing on  their  dorsal  surfaces  with  the  dis- 
engaged hand.  Auscultation  is  some- 
times successful  when  palpation  fails, 
and  a  combination  of  the  two  has  led 
to  the  detection  of  a  friction-sound.  In 
attempting  the  latter  mode  of  examina- 
tion the  stethoscope  should  be  placed 
just  below  the  costal  arch,  in  order  to 
allow  space  for  the  palpating  right  hand 
over  the  fundus  of  the  gall-bladder.  J. 
M.  Anders  (Inter.  Med.  Mag.,  Dec,  '99). 

Palpation  for  the  lower  margin  of  the 
liver  should  be  conducted  in  the  follow- 
ing manner:  The  physician,  seated  to 
the    right    of    the    recumbent    patient, 


2—8 


places  the  left  hand  fiatly  on  the  abdo- 
men in  the  hepatic  region,  and  endeavors 
by  means  of  gentle  pressure  with  the 
tips  of  the  fingers  to  ascertain  the  situ- 
•ation  of  the  lower  edge  of  the  liver. 
When  he  thinks  he  is  near  to  the  liver's 
edge,  the  fingers  of  the  right  hand  are 
placed  obliquely  upon  the  left  (the  right 
indc.K  finger  corresponding  to  the  left 
little  finger,  and  vice  versa)  in  such  a 
manner  that  the  tips  of  the  fingers  of 
the  right  hand  slightly  overhang  those 
of  the  left.  Firm  pressure  is  exercised 
with  the  right  hand  upon  the  subjacent 
passive  left. 

If  by  means  of  this  "octodigital"  pal- 
pation the  liver-edge  cannot  be  felt  in 
the  right  mammary  line,  there  is  no 
hypertrophy  of  the  organ. 

If  the  liver  is  enlarged — especially  if 
its  volume  presents  manifest  fluctuations 
from  time  to  time,  augmenting  during 
the  attacks  of  pain  and  diminishing  in 
the  intervals — and  in  addition  abdominal 
tenderness  is  found  to  be  present,  a  diag- 
nosis of  hepatic  colic  may  be  made.  Pol- 
latschek  (La  Semaine  M6d.,  Apr.,  '99). 

The  characteristic  signs  of  gall-blad- 
der enlargements  are:  (1)  that  they 
are  continuous  with  the  upper  surface 
of  the  liver;  (2)  that  they  project 
sharply  from  the  margin  of  the  liver; 
(3)  that  the  margin  of  the  liver  can  be 
treated  to  a  gradually  diminishing  edge 
attached  to  the  upper  surface  of  a 
globular  mass.  In  the  relation  of  jaun- 
dice to  pain  the  author  states  that 
jaundice  due  to  gall-stones  is  always 
preceded  by  colic;  that  jaundice  due  to 
malignant  disease,  or  catarrh  of  the 
ducts  accompanied  with  infection,  is 
never  preceded  by  colic.  There  are  two 
striking,  contrasting  conditions  under 
which  pressing  gall-stones  do  not  pro- 
duce colic:  (1)  when  they  are  very 
small,  too  small  to  produce  obstruc- 
tions or  spasm  of  the  ducts;  (2)  when 
they  are  very  large,  so  large  that  the 
wall  is  paralyzed  by  the  overdistension 
and  infiltration  by  the  extremely  slow 
advance  of  the  stone.  Murphy  (Med- 
ical  Xews,   .May  2,   1903). 

If  after  a  careful  examination  into  the 
history  and  present  condition,  especially 


114 


CHOLELITHIASIS.     DIAGNOSIS. 


an  analysis  of  the  urine,  tlie  symptoms 
and  signs  are  found  to  be  hepatic  rather 
than  renal,  the  tumor  will  probably  be 
a  distended  gall-bladder.  As  before 
stated,  a  displaced  kidney  attached  to 
the  under-surface  of  the  liver  may  cause 
jaundice  by  drawing  the  common  bile- 
duct  out  of  place. 

^^^len  anatomical  conditions  are  fa- 
vorable, disease  of  the  pancreas  may 
occur  as  a  complication  of  cholelithiasis 
when  a  calculus  passes  along  the  com- 
mon bile-duct.  The  lodgment  of  a  stone 
near  the  orifice  of  the  bile-duct  where 
it  may  at  the  same  time  compress  and 
occlude  the  duct  of  Wirsung,  is  not  un- 
commonly a  cause  of  pancreatic  lesions 
and  disseminated  fat-necrosis.  Should  a 
calculus  become  impacted  in  this  posi- 
tion, one  of  several  conditions  may  re- 
sult:— 

1.  An  individual,  usually  in  fairly 
good  health,  with  perhaps  a  history  of 
previous  gall-stone  colic,  is  suddenly 
attacked  with  pain  in  the  epigastric 
region,  accompanied  by  vomiting  ana 
followed  by  collapse.  Death  follows 
usually  within  forty-eight  hours,  and  at 
autopsy  gall-stones  are  found  in  the 
bile-passages,  while  that  one  which 
caused  the  fatal  attack  may  be  still 
lodged  in  the  common  duct  near  its  ori- 
fice. The  pancreas  is  enlarged,  infil- 
trated with  blood,  and  hsemorrhage  may 
have  occurred  into  the  surrounding  tis- 
sue. Foci  of  fat-necrosis  are  usually 
present. 

2.  A  fatal  termination  may  not  follow 
rapidly  the  symptoms  mentioned.  Pain 
in  the  epigastrium  persists,  jaundice 
may  be  present,  and  a  tumor-mass 
above  the  umbilicus  may  indicate  a 
probable  lesion  of  the  pancreas.  At  the 
end  of  one  or  more  weeks  or  months 
death  occurs,  often  with  symptoms  in- 
dicating the  presence  of  suppurative  in- 
flammation, presumably  in  the  neighbor- 
hood of  the  gland.  At  autopsy  the  di- 
agnosis of  cholelithiasis  is  confirmed  by 
the  prcBcncc  of  gall-stones  in  the  gall- 
bladder or  in  tlie  bile-ducts,  and  occa- 
sionally the  offending  calculus  is  still 
lodged   near   the   junction   of   the   com- 


mon bile-duct  and  the  duct  of  \Virsung. 
The  pancreas  is  dry,  black,  and  necrotic, 
and  evidence  of  previous  haemorrhage 
may  be  present.  Secondary  infection 
has  occurred,  and  the  pancreas  lies  in 
an  abscess-cavity  formed  by  the  bursa 
omentalis.  In  the  wall,  and  often 
widely  disseminated  in  the  abdominal 
fat,  are  foci  of  necrosis.  Since  the  in- 
dividual has  survived  the  primary  le- 
sion, opportunity  has  been  given  for  the 
development  of  secondary  changes  in 
the  injured  pancreas  and  neighboring 
fat. 

3.  In  certain  instances  long-continued 
or  repeated  obstruction  of  the  pancre- 
atic ducts  by  gall-stones  does  not  cause 
the  acute  lesions  described,  but  pro- 
duces chronic  inflammatory  changes. 
E.  L.  Opie  (Amer.  Jour.  Med.  Sci.,  Jan., 
1901). 

A  distended  gall-bladder  may  require 
to  be  differentiated  from  pyloric  and  in- 
testinal carcinoma,  foecal  impaction  in 
the  colon,  tumor  of  the  liver  and  of  the 
right  kidney;  also  from  a  tongue-like 
projection  of  the  liver,  which  is  occa- 
sionally found. 

Attention  called  to  cases  of  acute 
cholecystitis  of  sudden  onset  in  patients 
of  apparently  perfect  health,  in  which 
there  is  no  history  of  gall-stones  and 
which  do  not  depend  on  typhoid  fever, 
pneumonia,  or  other  infective  processes. 
Of  59  cases  of  cholecystitis  personally 
operated  on  only  10  began  without 
known  pre-existing  disease.  Three  of  the 
10  cases  were  diagnosed  as  acute  appen- 
dicitis with  such  certainty  that  the  in- 
cision was  made  over  the  appendix.  In 
3  the  symptoms  were  those  of  acute  in- 
testinal obstruction. 

Again,  the  disease  may  be  mistaken  for 
the  sudden  closure  of  an  organic  stric- 
ture, for  an  inflammatory  process  in  a 
diseased  kidney,  an  acute  peritonitis,  an 
acute  pancreatitis, an  extravasation  from 
the  stomach,  a  malignant  abdominal 
tumor,  or  a  tumor  with  a  twisted  pedicle. 
If  the  symptoms  point  to  the  gall- 
bladder rather  than  to  the  appendix  the 
incision  should  be  made  over  tlie  former 
and   vice  versa.     When   tlicre   is  great 


CHOLELITHIASIS.    FKOGNOSIS. 


115 


doubt  as  to  which  is  affected,  the  cut 
may  be  made  behind  tlie  c£ECum,  high  up 
and  enlarged  in  whichever  direction  la 
required.  When  there  is  no  localized 
pain  or  tumor  or  history  pointing  to  a 
definite  lesion,  the  incision  should  be  in 
the  middle  line. 

Seven  of  the  10  cases  recovered.  Rich- 
ardson (Amer.  Jour.  Med.  Sciences,  June, 
'98). 

There  are  three  prominent  symptoms 
of  cholelithiasis  in  infancy  and  in  child- 
hood upon  which  the  diagnosis  is  often 
based,  namely:  pain,  vomiting,  and  con- 
vulsions. Pain  is  usually  referred  to  the 
epigastrium  and  is  indicated  in  children 
by  paro.xysms  of  crying  attended  with 
severe  vomiting.  One  of  the  most  valu- 
able diagnostic  signs  is  persistence  of  the 
sensitiveness  of  the  gall-bladder  after 
cessation  of  the  symptoms  of  the  colic. 
The  best  means  of  eliciting  this  symptom 
is  by  placing  the  child  in  a  warm  bath, 
which  will  serve  to  distract  its  attention 
and  at  the  same  time  relax  the  muscular 
structures.  The  Rentini  symptom,  pain 
around  the  xiphoid  cartilage  from  gall- 
stones during  their  expulsion,  is  deserv- 
ing of  particular  attention.  Vomiting  is 
usually  persistent. 

Fever,  chills,  costal  respiratory  move- 
ments of  a  jerky  character  when  the  pa- 
tient is  placed  in  a  sitting  posture,  are 
some  of  the  other  symptoms  that  aid  in 
establishing  the  diagnosis.  In  young 
persons  jaundice  caused  by  gall-stones 
without  pain  is  rare.  In  doubtful  cases 
the  urine  should  be  evaporated  on  a 
water-bath  to  abotit  one-tenth  its  origi- 
nal volume  and  tested  for  biliary  color- 
ing-matter and  biliary  salts.  Acholic 
feeces  in  children  are  not  necessarily 
white;  frequently  they  present  a  green- 
ish color,  with  putrid  odor  and  diarrhoeal 
tendencies.  A.  V.  Wendel  (Med.  Rec, 
July  9,  '98). 

Number  of  successful  radiographs  of 
gall-stones  obtained.  The  longer  the 
time  of  exposure,  the  clearer  the  liver 
and  the  more  obscure  the  calculi.  About 
five  or  six  minutes  gives  the  best  results. 
The  patient  should  lie  upon  the  abdo- 
men with  a  pillow  underneath  his  sym- 
physis and  clavicles.  The  rays  shall  not 
penetrate  the  abdomen  in  a  vertical  di- 


rection, but  should  form  an  angle  of 
about  45  degrees  with  the  plate.  A  great 
deal  also  depends  upon  the  composition 
of  the  stone,  which  is  far  more  complex 
than  that  of  renal  calculi.  Calculi  con- 
sisting of  pure  cholesterin  give  but  an 
indistinct  shade,  while  those  containing 
quantities  of  calcium  are  well  shown. 
Calculi  which  consist  of  a  compound 
of  calcium  and  bilirubin,  or  carbonic 
acid,  are  distinctly  brought  out  by  the 
rays.  Carl  Beck  (N.  Y.  Med.  Jour.,  Jan. 
20,  1900). 

Prognosis. — The  presence  of  calculi  in 
the  gall-bladder  is  not  of  so  much  im- 
portance when  they  do  not  give  rise  to 
any  pronounced  symptoms;  but  in  all 
cases  they  are  to  be  looked  upon  as  for- 
eign bodies  which  may  at  any  time  give 
rise  to  dangerous  symptoms.  When 
phlegmonous  inflammation  of  the  gall- 
bladder takes  place,  the  prognosis  is 
grave. 

Biliary  colic  is  not  always  free  from 
danger.  Some  cases  of  death  from  heart- 
failure  have  been  recorded.  Distended 
gall-bladder  from  calculous  obstruction 
of  the  cystic  duct  when  accompanied  by 
elevation,  and  irregularity  of  tempera- 
ture, with  local  pain  and  tenderness, 
suggests  the  possibility  of  suppuration. 
Cholecystitis  may  result  in  rupture  of 
the  gall-bladder  or  in  general  septi- 
caemia. Both  conditions  usually  ter- 
minate fatally. 

.  Hepatic  and  perihepatic  abscesses  are 
of  grave  import.  The  prognosis  of 
jaundice  depends  on  the  amount  of  ob- 
struction and  the  previous  health  of  the 
patient.  If  the  jaundice  is  intermittent 
or  remittent,  as  is  the  case  when  a  cal- 
culus floats  in  an  enlargement  of  the 
common  duct,  the  danger  is  not  great, 
because  the  system  will  eliminate  the 
poison  in  the  interval. 

If  the  patient  have  a  poor  constitution 
or  if  the  kidneys  are  diseased;  a  mod- 
prate   amount   of   jaundice   may    prove 


116 


CHOLELITHIASIS.    ETIOLOGY. 


serious.  The  grave  symptoms  of  jaun- 
dice are  a  slow  pulse,  lethargj-,  and  the 
occurrence  of  hemorrhages  through  the 
mucous  membrane  or  into  the  tissues. 

Gall-stone  operations  in  jaundiced 
cases  are  much  more  hazardous  than 
those  done  when  that  condition  is  ab- 
sent. 

The  prognosis  of  cholelithiasis  is 
much  more  favorable  since  the  develop- 
ment of  hepatic  surgery,  and  the  experi- 
ence of  the  last  two  or  three  years  would 
seem  to  indicate  that  it  is  possible  to 
remove  calculi  in  the  most  difficult  cases 
with  comparative  safety  if  the  patient  be 
not  allowed  to  become  too  much  poi- 
soned by  the  toxins  of  bile  and  by  those 
resulting  from  membranous  infection. 

Etiology. — Biliary  calculi  have  been 
found  at  all  ages,  even  in  newborn  chil- 
dren. The  fact  is  well  established  that 
cholelithiasis  increases  in  frequency  with 
advancing  years.  According  to  Schroe- 
der's  statistics  as  given  by  Waring,  gall- 
stones were  present  in  the  following  per- 
centages of  cases: — 

Under  20  years,  2.4  per  cent. 
Between  20  and  30  years,  3.2  per  cent. 
Between  30  and  40  years,  11.5  per 
cent. 

Between  40  and  50  years,  11.1  per 
cent. 

Between  50  and  60  years,  9.9  per  cent. 
Over  CO  years,  25.2  per  cent. 
Krauss  found  in  actual  practice  that 
gall-stones  diagnosed  by  symptoms  dur- 
ing life  occurred  most  frequently  in  men 
between  the  40th  and  GOth  years,  and 
in  women  between  the  30th  and  50th 
years.  Recklinghausen's  statistics  of  aU' 
topsies  made  between  1880  and  1887 
give  the  percentage  of  all  stones:  4.4 
per  cent,  of  men  and  in  20.6  per  cent,  of 
women. 

Of   0.3,000    patientB   examined,   stones 
were  noted  in  only  133,  making  0.14  per 


cent.,  while,  on  the  other  hand,  at  autop- 
sies fully  10  per  cent,  of  the  bodies  are 
found  to  possess  them  if  a  careful  exam- 
ination of  the  biliary  system  is  made. 
The  great  frequency  with  which  gall- 
stones are  not  diagnosed  intra  litam  is 
thus  shown.  The  Koentgen  rays  may 
be  looked  upon  as  a  valuable  diagnos- 
tic aid  in  the  future,  and  already  a  num- 
ber of  excellent  photograms  have  been 
published.  Best  results  will  always  be 
obtained  with  the  strongly  calcareous 
stones,  while  the  rarer  ones,  consisting 
chiefl}'  of  cholestrin  or  bile-pigment,  can 
hardly  be  expected  to  throw  a  shadow. 
H.  Fiedler  (Miinchener  med.  Wochen., 
Oct.  22,  1901). 

Pending  the  study  of  other  series  of 
cases  from  various  parts  of  the  United 
States,  one  may  draw  the  following 
conclusions: — 

Nationality:  On  the  basis  of  the 
analysis  of  the  1655  autopsies  from  the 
Johns  Hopkins  Pathological  Depart- 
ment, as  compared  with  1150  (?)  cases 
as  given  by  Schroder,  of  Strassburg, 
gall-stones  are  less  frequent  in  the 
United  States  than  in  Germany,  the 
United  States  showing  a  frequency  of 
6.94  per  cent.;    Germany,  of  12  per  cent. 

Age:  The  frequency  of  gall-stones  in 
a  given  number  of  cases  will  increase 
with  the  age  of  the  patients  examined. 
The  American  cases  tend  to  confirm  the 
statements  of  previous  observers  that 
gall-stones  are  rare  before  the  thirtieth 
year  and  more  frequent  after  that  age. 

Color:  Gall-stones  are  more  frequent 
in  the  white  man  than  in  tlie  black,  the 
American  cases  sliowing  a  frequency  of 
7.85  per  cent,  in  the  whites  and  5.51  per 
cent,  in  the  negro. 

Sex:  Women  are  more  liable  to  have 
gall-stones  than  are  men,  the  American 
eases  showing  the  frequency  in  018 
women  to  be  9.37  per  cent.,  and  in  1037 
men  to  be  5.94  per  cent.  Tlie  American 
women  have  gall-stones  only  about  half 
as  freqiiently  as  the  German  women. 
In  the  United  States  only  about  1 
woman  in  every  10  has  biliary  calculi, 
while  in  Germany,  according  to  Naunyn, 
gall-stones  are  found  in  20.0  per  cent., 
or  in  about  1  woman  in  every  5.     C.  D. 


CHOLELITHIASIS.    ETIOLOGY. 


117 


Mosher     (Johns    Hopkins    Hosp.    Bull., 
Aug.,  1901). 

In  women  the  largest  number  of  cases 
occur  in  the  child-bearing  period,  and, 
according  to  Schroeder,  90  per  cent,  of 
the  females  were  women  who  had  borne 
children.  The  fact  that  cholelithiasis 
occurs  in  females  in  the  proportion  of  4 
or  5  to  1  of  males  is  established  by  all 
statistics.  Tight-lacing  has  been  given 
a  very  prominent  place  in  the  causation 
by  some  authors.  In  more  than  half  of 
the  female  cases  the  liver  has  shown 
signs  of  pressure  of  the  ribs. 

A  pendulous  abdomen  is  often  found, 
which  may  favor  the  formation  of  cal- 
culi directly  in  causing  a  partial  ob- 
struction of  the  bile  by  traction  on  the 
common  bile-duct. 

Langenbuch  is  of  the  opinion  that 
the  traction  of  a  displaced  right  kidney 
on  the  common  duct  is  a  predisposing 
cause  of  cholelithiasis  to  which  suffi- 
cient importance  has  not  been  given. 
The  capsule  is  attached  to  the  cystic 
duct,  the  hepatico-duodenal  being  con- 
tinous  with  the  hepatico-renal  ligament. 

As  profession  and  social  position  as 
causative  factors,  Krauss  gives  the  fol- 
lowing statistics  of  473  cases  in  men 
which  came  under  his  observation: — 

Physicians,  45. 

Officials,  74. 

Manufacturers,  19. 

Clergymen,  60. 

Large  landed  proprietors,  24. 

Merchants  and  bankers,  40. 

Small  land-owners,  26. 

Military  officers,  40. 

Professors  and  teachers,  103. 

Tenants,  41. 

Over  50  per  cent,  occurred  in  active 
brain-workers  who  at  the  same  time  lead 
sedentary  lives.  Krauss  gives  mental 
anxiety,  chronic  constipation,  and  fre- 
quent pregnancies   as   probable   causes. 


He  is  also  of  the  opinion  that  the  de- 
posit of  fat  in  the  abdomen  prevents  the 
active  peristalsis  of  the  intestines. 

Heredity  does  not  seem  to  play  an 
important  part.  Naunyn  claims  that  it 
would  be  difficult  to  estimate  this  factor 
in  a  disease  so  prevalent.  In  60  per 
cent,  of  Krauss's  patients  the  disease 
could  be  traced  in  the  families  of  the 
patient.  He  has  often  treated  mothers 
and  daughters  for  cholelithiasis  at  the 
same  time. 

Gout  has  been  looked  upon  as  a  pre- 
disposing cause.  It  may  act  in  two  ways: 
by  producing  a  stagnation  of  bile  in  one 
who  cannot  take  sufficient  exercise,  and 
by  means  of  toxins  which,  when  excreted 
by  the  liver,  may  bring  about  a  catarrhal 
inflammation  of  the  ducts. 

The  relation  between  diabetes  and 
cholelithiasis  has  given  rise  to  much  dis- 
cussion. Bouchard  found  gall-stones 
present  in  165  cases  of  diabetes.  Mayo 
Robson  states  that  they  are  rarely  found 
in  case  of  diabetes  when  nitrogenous 
food  is  largely  taken. 

Cardiac  disease  tends  to  the  formation 
of  calculi  by  rendering  the  patient  in- 
capable of  much  exercise,  and  by  causing 
passive  congestion  of  the  liver.  Brock- 
bank  found  gall-stones  in  27  out  of  49 
cases  of  heart  disease. 

Eenal  calculi  were  found  so  frequently 
in  gall-stone  cases  that  a  definite  rela- 
tionship was  thought  to  exist  between 
the  two  conditions.  On  the  other  hand, 
Naunyn  has  rarely  found  tlie  two  dis- 
eases combined. 

A  villous  condition  of  the  inner  sur- 
face of  the  gall-bladder  has  been  given 
as  a  predisposing  cause. 

It  is  generally  thought  that  cancer, 
with  which  cholelithiasis  is  so  frequently 
combined,  is  caused  by  irritation  of  the 
calculi.  It  would,  however,  seem  prob- 
able  that   roughening   of   the   surface. 


118 


CHOLELITHIASIS.    ETIOLOGY. 


catarrhal  cholecystitis  and  cholangitis, 
which  frequently  occur  in  the  early 
stage  of  the  disease,  as  well  as  the  par- 
tial obstruction  which  must  often  take 
place,  would  all  predispose  to  the  forma- 
tion of  calculi. 

Gall-stones  probably  form  around  a 
nucleus  of  precipitated  bile-salt  result- 
ing entirely  from  local  changes.  The 
calcium  salts  and  bile-pigments  are  read- 
ily precipitated  Tvhenever  there  is  an  in- 
crease in  the  albuminous  constituents 
of  the  bile,  and  this  increase  is  par- 
ticularly marked  when  inflammatory 
changes  occur  in  the  bUe-passages. 
Cholesterin  is  especially  abundant  when 
any  degenerative  process  is  going  on, 
as  there  would  be  in  disease  of  the  gall- 
ducts,  and  this  cholesterin  is  deposited 
around  the  nucleus.  The  most  frequent 
causes  of  such  catarrh  is  infection  by 
micro-organisms,  the  bacilli  coli  com- 
munis and  the  typhoid  bacilli  being  par- 
ticularly apt  to  originate  such  disturb- 
ances. The  latter  may  have  laid  dor- 
mant for  many  years  before  acting  as 
an  exciting  agent.  W.  H.  Thomson 
(New  York  Med.  Jour.,  March  1,  1902). 

The  relation  which  insanity  bears  to 
cholelithiasis  has  long  excited  interest. 
The  more  frequent  occurrence  of  gall- 
stones in  insane  people  is  probably  due, 
in  large  measure,  to  their  sedentary 
habits.  The  opinion  has  also  been  given 
that  great  nerve-waste  may  produce  an 
excess  of  cholesterin. 

Sedentary  habits  are,  no  doubt,  a 
very  important  predisposing  cause.  The 
flow  of  bile,  which  under  ordinary  cir- 
cumstances takes  place  under  very  low 
pressure,  is  much  influenced  by  the 
movements  of  the  body  and  especially 
by  the  movements  of  the  diaphragm. 
When,  therefore,  the  body  is  in  com- 
plete repose,  stagnation  of  the  bile  will 
more  readily  take  place,  and  the  soft 
cholesterin  masses  which  form  the  nu- 
clei of  gall-stones  do  not  pass  out  of  the 
gall-bladder,  but  are  coated  by  a  more 


dense  layer  of  cholesterin  or  bilirubin- 
calcium,  and  thus  become  too  large  to 
pass  through  the  cystic  duct.  Condi- 
tions which  interfere  with  the  movement 
of  the  diaphragm — such  as  empyema 
and  pregnancy — have  the  same  efliect. 

Authoritative  views  with  regard  to  the 
influence  of  diet  have  been  divided,  and 
of  late  years  its  importance  has  been 
much  doubted.  Experience  has  shown 
that,  in  cases  of  biliary  fistula,  fari- 
naceous and  saccharin  food  will  produce 
a  dense,  thick  bile,  whereas  an  albumi- 
noid diet  will  cause  the  biliary  secretion 
to  be  more  liquid.  A  dense,  thick  bile 
will  act  in  the  same  way  as  if  it  were 
stagnant:  in  favoring  the  formation  of 
calculi.  Frerichs  thought  that  a  small 
number  of  meals,  with  too  long  an  in- 
terval between  them,  prevented  the 
proper  emptying  of  the  gall-bladder, 
and  thus  predisposed  to  the  formation 
of  calculi. 

It  was  at  one  time  thought  tliat  too 
much  lime  in  drinking-water  predis- 
posed to  cholelithiasis;  this  has,  how- 
ever, not  been  substantiated.  Climate 
does  not  seem  to  have  any  great  influ- 
ence. 

A  summary  of  our  present  knowledge 
regarding  tlie  etiology  of  cholelithiasis 
shows  that  gall-stones  may  originate 
either  in  the  gall-bladder  or  in  the  intra- 
hepatic ducts.  In  a  large  majority  of 
cases  they  occur  in  the  former  situation 
and  are  the  result  of  catarrhal  and  other 
inflammations.  The  formation  of  bili- 
rubin calculi  in  the  intrahepatic  ducts 
is  caused  by  catarrhal  inflammation, 
probably  the  result  of  the  excretion  of 
some  irritating  substance.  It  is  pos- 
sible, also,  that  a  microbic  invasion  may 
take  place  either  through  the  common 
bile-duct  or  from  the  blood-vessels;  but 
the  latter  is  not  likely.  Bilirul)in-ca]- 
cium  calculi  may  form  in  the  intrahe- 


CHOLELITHIASIS.    PATHOLOGY. 


119 


patic  ducts  and  pass  through  into  the 
gall-bladder,  becoming  the  nuclei  of 
larger  stones. 

The  principal  predisposing  cause  is  the 
stagnation  of  bile,  and  this  may  arise  ! 
either  from  its  inherent  density  or  from  i 
partial  obstruction.  In  the  various  pre- 
disposing conditions  given  it  wll  be 
found  on  examination  that  they  all  act 
in  the  same  way,  viz.:  in  lessening  the 
pressure  of  the  flow  of  bile  through  the 
common  duct.  It  is  not  impossible  that 
chemical  conditions,  such  as  have  been 
described  by  Thudicum  and  the  French 
writers,  may  underlie  the  formation  of 
calculi,  but  certainly  the  existence  of 
such  conditions  has  never  been  demon- 
strated. 

Typical  calculi  produced  in  gmnea-pigs 
and  following  results  obtained:  Foreign 
bodies  when  introduced  into  the  gall- 
bladder can  stay  there  for  an  indefinite 
time,  provided  they  are  aseptic,  without 
causing  inflammation  or  precipitating 
the  solids  from  the  bile.  When  the 
foreign  bodies  are  previously  impregnated 
with  virulent  micro-organisms,  however, 
they  cause  a  more  or  less  intense  chole- 
cystitis and  precipitate  the  solids  from 
the  bile.  As  long  as  the  bacteria  retain 
their  virulence  they  cannot  form  a  cal- 
culus, but  only  a  sediment  mixed  with 
pus.  This  precipitate  has  no  tendency 
to  cohere  or  to  adhere  to  foreign  bodies. 
Five  or  six  months  are  required  for  the 
formation  of  a  perfect  calculus.  The 
kind  of  bacteria  injected  seems  to  be  of 
quite  secondary  importance.  Mignot 
(Arch.  Gen.  de  Med.,  Aug.,  '98). 

Biliary    calculi    may    be     caused    by 
cholestcrin,  bilirubin  calcium  precipitated 
by  changed  reaction,  bacteria  of  various 
types,  and  foreign  bodies.      Gall-stones 
are  uncommon  in  childhood,  rare  under 
thirty,  somewhat  common  between  thirty   I 
and  sixty,  usual  after  sixty  years.     Fe-   | 
males  suHer  from  them  in  the  ratio  of  4   ! 
to  2.    Anything  predisposing  to  stasis  is 
a  potent  cause.     The  bacillus  coli  com- 
munis   and    bacillus    typhosus    are    the   i 
most  potent  generators  of  biliary  calculi.   1 


F.  C.  Shatluek   (Phila.  Med.  Jour.,  Oct. 
6,  1900). 

Patholo^. — FoRMATiox  OF  Calculi. 
— Cholesterin,  the  principal  constituent 
of  biliary  calculi,  is  constantly  found  in 
the  bile,  being  kept  in  solution  by  the 
biliary-acid  salts:  the  glycocholate  and 
taurocholate  of  soda.  It  is  not  found  in 
the  blood,  nor  in  the  liver,  unless  there 
be  necrosis  of  the  hepatic  cells.  It  must, 
therefore,  be  produced  by  the  epithelial 
lining  of  the  bile-ducts  and  gall-bladder. 
Its  precipitation  will  depend  either  upon 
its  increased  proportion  in  the  bile,  or 
upon  the  diminished  solvent  power  of 
the  latter  fluid.  TPTiere  both  conditions 
exist  together,  the  process  of  concretion 
is  still  more  favored. 

Although  the  quantity  of  cholesterin 
in  the  normal  bile  is  fairly  constant,  it 
may  be  considerably  increased  by  inflam- 
mation of  the  mucous  membrane  of  the 
gall-bladder  and  passages.  The  same 
condition  produces  a  lessened  alkalinity 
of  the  bile,  which  diminishes  its  solvent 
power.  It  is  thus  seen  that  catarrhal 
inflammation  at  once  produces  the  two 
conditions  favorable  to  the  precipitation 
of  cholesterin.  The  process  may  be  set 
up  by  such  germs  as  the  colon  bacillus, 
the  typhoid  bacillus,  and  the  pneumo- 
coccus.  The  fact  that  such  organisms 
have  been  found  in  the  nuclei  of  calculi 
confirms  the  theory  of  this  method  of 
their  origin,  which  was  elaborated  by 
Naunyn  in  his  work  published  in  1892. 
The  presence  of  a  nucleus  of  bilirubin- 
calcium  or  cholesterin  is  not  of  itself 
sufflcient  to  give  rise  to  a  calculus.  This 
has  been  proved  by  experiments  upon 
dogs.  Cholesterin  calculi,  according  to 
Naunyn,  may  form  in  two  ways:  either 
with  small  cholesterin  masses  as  nuclei, 
or  small  aggregations  of  sediment  be- 
come the  centre  of  calculi.     This  sedi- 


r^o 


CHOLELITHIASIS.     PATHOLOGY. 


ment  consists  of  brownish  particles  and 
yellow,  gritty  masses  in  which  fat-gran- 
ules and  cholesterin  crystals  are  often 
present. 

A  comparatively-soft  nucleus  may  be 
surrounded  by  a  hard  layer  of  choles- 
terin. When  a  calculus  is  once  formed 
it  increases  in  size,  layer  upon  layer.  The 
crystallization  of  the  cholesterin  takes 
place  within  the  calculus  after  its  forma- 
tion. 

The  portal  of  entry  of  the  micro-or- 
ganism is  probably  the  duodenal  opening 
of  the  common  bile-duct.  It  is  also 
probable  that,  in  the  great  majority  of 
cases,  the  germs  pass  into  the  gall-blad- 
der and  not  into  the  intrahepatic  ducts. 
The  possibility  of  entrance  through  the 
blood-vessels  must  be  allowed,  but  has 
not  been  proved. 

Naunyn  is  of  opinion  that  the  colon 
bacillus  is  the  principal  agent  in  the 
production  of  calculi.  Within  the  last 
few  years  the  relationship  between  ty- 
phoid fever  and  cholelithiasis  has  been 
studied  by  Osier,  of  Baltimore;  Hunter, 
of  London;  and  others.  The  frequency 
with  which  the  latter  disease  follows 
typhoid,  and  the  fact  that  Eberth's 
bacillus  has  so  often  been  found  in  the 
gall-bladder  of  those  who  die  of  typhoid 
fever,  are  interesting  facts  in  this  con- 
nection. 

Conclusions  arrived  at,  largely  from 
experiments  upon  animals: — 

L  The  presence  of  aseptic  foreign  bod- 
ies in  tlie  gall-bladder  does  not  produce 
inflammation  and  does  not  soem  to  affect 
it8  function,  if  the  cystic  duct  remain 
patent.  There  is  no  precipitation  of  cho- 
lesterin when  the  bile  remains  clear  and 
free  from  microbes. 

2.  15ilc  stagnant  in  an  aseptic  gall- 
bladder has  no  tendency  to  precipitate. 

3.  There  is  greater  tendency  to  pre- 
cipitation when  the  infection  is  from  «n 
attenuated,  than  from  a  strong,  virus. 
n.  Mignot  (Thfsf  de  Paris,  '00). 


Xaunyn's  theoiy  tlmt  gall-stones  are 
the  result  of  catarrhal  inflaamiation  of 
the  lining  mucous  membranes  not  ac- 
cepted. In  most  cases  they  result  from 
a  decomposition  of  the  bile  into  simpler 
substances,  such  as  are  produced  more 
particularly  during  the  process  of  so- 
called  spontaneous  decomposition  after 
its  removal  from  the  body. 

Those  who  look  at  the  formation  of 
gall-stones  as  simply  the  result  of  local 
changes,  and  do  not  study  the  general 
constitutional  conditions  which  give  rise 
to  them  are  like  those  of  whom  Stro- 
meyer  speaks:  "They  bear  the  little 
grass  grow  while  the  thunder  rolls  un- 
observed in  the  upper  ether."  J.  L.  W. 
Thudicum  (Med.  Press  and  Circular,  vol. 
Ixiv,  208-210,  '97). 

Experimental  formation  of  gall-stones. 
Three  drops  of  a  culture  of  typhoid  ba- 
cilli were  injected  in  the  gall-bladder  of 
a  rabbit.  At  the  autopsy,  six  weeks 
afterward,  two  small  calculi  about  the 
size  of  grains  of  wheat  were  found  in  the 
gall-bladder.  They  were  made  up  of  a 
whitish  kernel  inclosed  in  a  dark-colored 
shell.  A  pure  culture  of  typhoid  bacilli 
was  made  from  the  nucleus  of  one  of 
them.  Gilbert  and  Foumier  (Deutsche 
mod.  Woch.,  Dec, '97). 

Case  of  formation  of  gall-stones  around 
sutures  allowed  to  remain  in  the  gall- 
bladder after  a  cholecystotomy.  The 
gall-bladder  was  entirely  emptied  of 
stones  in  April,  1895,  and  in  January, 
1897,  several  round  and  oval  calculi  were 
found.  Sutures  formed  the  nucleus 
of  each.  {Seo  colored  plate.)  John 
Homans  (Surg.  Annals,  July,  '!)7). 

The  simple  presence  of  organisms  in 
the  gall-bladder  does  not  seem  sufficient 
to  set  up  inflammation  of  the  mucosa  nor 
to  produce  cholelithiasis.  Some  other 
factor,  ijrcRuniably  some  form  of  irrita- 
tion, such  as  traumatism  or  some  hin- 
drance to  the  proper  evacuation  of  the 
gall-bladder,  is  essential.  Gushing 
(Johns  Hopkins  Hosp.  Pull.,  Aug.-Sept., 
'09). 

Elfects  of  introducing  cholcHterin  cal- 
culi or  fragments  of  calculi  into  the 
gall-bladder  of  dogs,  both  in  health  and 
ill    viu'ious   morbid   states.     A   series   of 


CHOLELITHIASIS.    PATHOLOGY. 


121 


five  experiments  all  gave  similar  re- 
sults to  the  following  experiment: 
Two  cholesterin  fragments  were  intro- 
duced into  the  gall-bladder;  the  dog 
was  killed  2G5  days  later  and  autopsy 
performed.  Both  gall-stone  fragments 
had  disappeared;  the  gall-bladder,  cys- 
tic duct,  and  bile  were  all  healthy  in 
aspect.  All  the  animals  had  remained 
in  good  health  except  one,  which  lost 
weight.  In  a  second  scries  of  experi- 
ments, besides  the  calculi,  dry  pus  or 
pus  containing  the  Bacillus  coli  was  in- 
troduced. The  dogs  remained  in  ap- 
parently perfect  health ;  nevertheless  the 
autopsy  revealed  cholecystitis,  and  no 
dissolution  of  gall-stones  occurred.  In 
two  experiments  where  only  gall-stonea 
were  introduced  the  latter  were  found 
unaltered,  but  cholecystitis  was  pres- 
ent and  bacilli  were  found  in  the  con- 
tents of  the  gall-bladder.  It  would 
therefore  appear  that  when  the  gall- 
bladder is  healthy  the  gall-stones 
seemed  to  disappear;  on  the  other 
hand,  where  cholecystitis  was  present 
the  gall-stones  remained  unchanged. 
In  the  second  series  of  cases  the  follow- 
ing changes  were  met  with:  The  colum- 
nar epitheli\un  of  the  mucous  mem- 
brane of  the  gall-bladder  was  in  every 
case  covered  with  an  amorphous  or 
finely  reticulated  deposit,  which  could 
not  be  well  stained  with  a  fibrin  stain 
nor  with  any  of  the  other  stains  era- 
ployed.  Sometimes  this  deposit  con- 
tained micro-organisms.  The  epithelial 
cells  themselves  were  swollen  and  pre- 
sented in  the  middle  and  upper  part  of 
their  cytoplasm  a  clear,  vacuolated  as- 
pect. Lying  among  the  epithelial  cells, 
wandering  cells  could  also  be  seen  in 
sparse  numbers.  The  connective  tissue 
of  the  mucous  coat  sometimes  appeared 
wide-meshed  as  if  oedematous,  and  the 
capillaries  of  the  mucous  membrane 
were  sometimes  congested.  V.  Harley 
and  W.  Barratt  (Jour,  of  Phys.,  Jime 
15,  1003). 

Bilirubin-calcium  is  insoluble  in 
water,  and  cannot  be  formed  simply  by 
concentrating  tbe  bile.  It  bas  been 
found  that  egg-albumin  will  aid  in  the 
precipitation  of  bilirubin-calcium  from 


bile.     It  is  probable  that  albumin  may 
act  similarly  in  pathological  processes. 

Formation  of  biliary  calculi  does  not 
take  place  solely  in  the  gall-bladder. 
Some  are  formed  in  the  ramifications  of 
the  hepatic  duet.  Cholesterin  and  cal- 
cium (bilirubinate  of  lime),  the  chief 
chemical  constituents  of  biliary  calculi, 
come  from  the  mucous  membrane  of  the 
biliary  ducts.  Lithogenie  catarrhs  of  the 
mucous  membrane  may  be  excited  by 
microbes  (coli  bacillus,  Eberth's  bacillus, 
possibly  also  by  others).  Great  virulence 
of  the  germs  is  by  no  means  favorable  to 
the  formation  of  concretions.  Slight  in- 
fections may  become  developed  as  soon 
as  there  is  stagnation  of  bile.  Naunyn 
(Intern.  Med.  Congress;  Brit.  Med.  Jour., 
Sept.  29,  1900). 

The  formation  of  bilirubin-calcium 
stones,  as  has  been  already  intimated, 
takes  place  in  the  intrahepatic  ducts. 
Naunyn  and  others  are  of  opinion  that 
the  calcium  results  from  an  inflamma- 
tion of  the  lining  membrane  of  the  ducts, 
from  the  presence  of  microbes.  It  would 
seem  difficult  to  understand  how  micro- 
organisms find  their  way  from  the  duo- 
denum into  the  smaller  bile-ducts,  and 
still  more  difficult  to  conceive  of  their 
entering  the  intrahepatic  ducts  from  the 
blood  without  seriously  affecting  the 
parenchyma  of  the  liver.  As  has  been 
already  noticed,  William  Hunter,  of 
London,  is  of  the  opinion  that  calculi 
of  the  intrahepatic  ducts  is  caused,  not 
by  micro-organisms,  but  by  toxins  ex- 
creted by  the  liver.  The  function  of  the 
liver  as  an  excretory  organ  has  been 
amply  proved  by  Schiff  and  others,  and 
a  catarrhal  inflammation  from  this  cause 
seems  reasonable. 

Spontaneous  fracture  of  biliary  calculi 
sometimes  takes  place. 

Morbid  Anatomy. — The  gall-bladder 
may  be  distended  with  calculi  and  little 


122 


CHOLELITHIASIS.    PATHOLOGY. 


change  found  except  erosion  of  the  mu- 
cous membrane,  with  more  or  less  thick- 
ening and  infiltration  in  places.  Chole- 
cj'stitis  and  pericholecystitis  may  cause 
these  changes  to  be  more  pronounced. 
Phlegmonous  inflammation  of  the  gall- 
bladder sometimes  occurs  in  acute  dis- 
eases. 

Calcification  of  the  gall-bladder  some- 
times follows  empyema,  in  which  the 
mucous  membrane  may  be  coated  or  the 
whole  thickness  of  the  wall  may  become 
infiltrated  with  lime-salts. 

Distension  of  the  gall-bladder  usually 
arises  from  the  arrest  of  calculi  in  the 
cystic  duct.  The  contents  in  uncom- 
plicated cases  are  largely  composed  of 
mucus,  more  or  less  bile-stained:  hydrops 
felleae.  If  at  the  same  time  there  is  an 
invasion  of  pyogenic  organisms,  an  em- 
pyema of  the  gall-bladder  results. 

Ulceration  and  perforation  sometimes 
occur,  allowing  the  contents  of  the  gall- 
bladder to  pass  into  the  peritoneal  cav- 
ity. 

Two  case3  of  distension  of  the  gall- 
bladder from  flexion  of  the  neck.  No 
gall-stones  were  found.  A.  H.  Ferguson 
(Brit.  Med.  Jour.,  Nov.  6,  '97). 

Fatal  ease  of  rupture  of  the  gall-blad- 
der. Patient  20  years  of  age.  The  gall- 
stones found  their  way  out  of  the  gall- 
bladder partly  by  ulceration  and  partly 
from  expulsion.  Some  gall-stones  and 
bile-stained  fluid  were  found  in  the  ab- 
domen, together  with  the  results  of  gen- 
eral peritonitis.  A  perforation  of  the 
rectum,  which  allowed  fa;ces  to  pass  out, 
was  also  discovered  at  the  post-mortem. 
The  perforation  thought  to  have  been 
caused  by  pressure  of  gall-bladder  stones 
on  the  peritoneal  coat  of  the  bowel.  The 
patient  lived  twenty-five  days  after  the 
rupture  of  the  gall-bladder.  Shadbad 
(St.  Petersburgcr  mcd.  Woch.,  Jan.,  '90). 

FiSTULiE. — Gall-stones  may  pass  out 
through  the  wall  of  the  gall-bladder  or 
ducts  into  the  surrounding  structures, 


producing  tistuliP,  which  may  take  dif- 
ferent directions. 

In  hepatico-bronchial  fistula  a  series 
of  cases  of  this  rare  form  of  disease 
studied  by  the  writer  showed  that  the 
opening  through  the  diaphragm  into  the 
gall-bladder  may  arise  from  a  distended 
gall-bladder  passing  over  the  anterior 
border  of  the  liver,  or  that  calculi  could 
find  their  way  by  ulceration  through  the 
wall  of  the  gall-bladder  and  duets,  form- 
ing an  abscess  which  may  penetrate  the 
convex  surface  of  the  liver  and  the  dia- 
phragm. In  such  cases  a  cavity  is  often 
formed  by  the  presence  of  intrahepatic 
calculi  and  of  pyogenic  organisms.  A 
direct  fistulous  opening  may  take  place 
between  the  gall-bladder  and  the  stom- 
ach. 

Case  of  obstruction  of  the  pylorus  pro- 
duced by  a  gall-stone  and  surrounding 
inflammatory  adhesions.  There  was  a 
direct  communication  between  the  gall- 
bladder and  stomach,  a  cystico-stomaclial 
fistula.  Monprofit  (Bull,  de  la  Soo. 
d'Anat.  de  Paris,  May,  June,  '97). 

Fistulous  openings  into  the  duodenum 
or  through  the  abdominal  walls  are  the 
most  common.  In  tlie  latter  case  open- 
ings may  take  place  in  the  right  hy- 
pochondrium,  near  the  umbilicus  and 
above  the  pubes. 

Interesting  ease  of  biliary  fistula  into 
the  urinary  tract.  The  post-mortem  re- 
vealed a  fistula  leading  into  an  abscess 
and  from  this  into  the  pelvis  of  the  right 
kidney,  where  a  large  cholesterin  calculus 
was  found.  Eisner  (Med.  News,  Feb.  ."i, 
'98). 

Courvoisier  has  reported  seven  cases  of 
urinary  fistulas.  Cases  of  fistute  into  the 
uterus  and  vagina  have  also  been  re- 
ported. The  chronic  irritation  resulting 
from  the  presence  of  calculi  in  the  gall- 
bladder and  ducts  may  give  rise  to 
atrophy  or  calcification  of  the  gall- 
bladder and  to  the  formation  of  diver- 
ticula and  cicatrices.    Tliickening  of  the 


CHOLELITHIASIS.    TKEATIIENT.    PREVENTIVE. 


123 


Burrounding  tissues  is  also  a  common  re- 
sult.   In  255  autopsies  in  gall-stone  cases 
given   by   Courvoisier,   atrophy   of   the 
gall-bladder   was   found   in    12  Yj   per 
cent.     It  is  the  result  of  frequent  ca- 
tarrhal inflammation.    In  such  cases  the 
gall-stones  are  found  imbedded  in  the 
contracted  gall-bladder  or  in  diverticula. 
The   obliteration  of  the  cystic  canal, 
the  gall-bladder  being  aseptic,  results  in 
atrophy  of  the  reservoir,  the  same  as  if 
it  contained  foreign  bodies  more  or  less 
irritating.    ArmCnis  {Th6se  de  Paris,  '90). 


paratively  rare,  the  connective  tissue  of 
the  liver  is  increased,  and  a  calculous 
biliary  cirrhosis  results.  It  is  very  dif- 
ficult, in  many  of  these  cases  of  cirrhosis, 
to  e.xclude  the  possibility  of  their  being 
caused  by  other  toxins;  alcohol,  for  in- 
stance. 

Treatment. — Prevextive. — The  par- 
tial or  complete  stagnation  of  bile  in  the 
gall-bladder  and  ducts  is  the  principal, 
if  not  the  only,  predisposing  cause  of  the 
formation  of  calculi.    Any  means,  there- 


1 

^&i 

^^ 

^K^-%L  wM^^l^^^sfWItlf^^ 

w 

c 

A,  Distended  gallbladder;  LI.  junction  of  cystic  and  hepatic  ducts;  C,  cup-shaped 
depression  in  surface  of  duodenum  at  the  entrance  of  the  common  bile-duct  in 
which  the  gall-stone  was  lodged.     (Dioycr.) 


A  calculus  in  the  common  bile-duct 
will,  after  awhile,  produce  distension  and 
thickening  of  the  wall  of  the  duct.  It 
sometimes  floats  in  a  cavity,  often  in  the 
ampulla  of  Vatcr,  acting  as  a  ball-valve, 
thus  causing  intermittent  or  remittent 
jaundice. 

The  enlargement  of  the  bile-ducts  may 
extend  backward  to  the  smaller  radicals. 
The  hepatic  cells  become  deeply  stained 
with  bile.    In  some  cases,  which  are  com- 


fore,  wliich  will  increase  the  watery  con- 
stituent of  the  bile  and  render  the  (low 
more  rapid  will  be  of  value  as  a  pro- 
phylactic agent.  Means  whereby  the  cir- 
culation is  stimulated  will  also  be  of 
service.  The  emptying  of  the  gall-blad- 
der and  ducts  may  be  brought  about  by 
exercise  and  by  internal  medication. 
Horseback  and  bicycle-riding  are  to  be 
especially  recommended,  as  well  as  tennis 
and  lawn  bowls  and  so  forth.    The  occa- 


124 


CHOLELITHIASIS.     TREATMENT.     MEDICAL. 


sional  administration  of  calomel  followed 
by  a  saline  cathartic  is  one  of  the  most 
effectual  methods  of  emptying  the  gall- 
bladder. The  taking  of  large  quantities 
of  water,  especially  of  Carlsbad  or  other 
alkaline  water,  an  hour  or  so  before 
meals  is  of  service,  as  the  liver  is,  in  that 
way,  flushed  out,  and  the  bile  flows  more 
freely. 

Ox-bile  used  internally  in  biliary  colic. 
The  bile  is  decolorized  to  get  rid  of  the 
toxic  coloring  matter  {especially  bili- 
rubin), and  then  sterilized  at  220°  to 
222°  F. ;  3  ounces  of  bile  produce  2 '/a 
drachms  of  the  extract.  Of  this  latter  3 
grains  in  pill  or  capsules  are  given  twice 
a  day  after  meals.  They  may  be  con- 
tinued for  years,  or  given  intermittently, 
whenever  there  is  any  sign  of  colic.  Ke- 
Bults  obtained  in  several  cases  have  been 
brilliant.  It  cannot,  however,  be  regarded 
aa  a  certain  preventive  of  colic,  since 
if  the  gall-bladder  is  full  of  stones  it  does 
not  cause  them  to  disappear,  though  it 
prevents  the  formation  of  fresh  calculi. 
The  treatment  is  recommended  after 
operations  for  the  evacuation  of  calculi 
to  prevent  relapses.  Gautier  (Rev.  M6d. 
de  la  Suisse  Rom.,  June  20,  '98). 

On  the  question  of  diet  there  is  much 
difference  of  opinion.  It  is,  however, 
safe  to  say  that  starchy  and  saccharin 
foods,  which  render  the  bile  more  dense, 
are  to  be  avoided. 

Medical  Treatment. — Some  writers, 
particularly  those  who  do  gall-stone 
surgery,  consider  remedial  measures  of  a 
medicinal  character  altogether  futile. 
It  is  quite  certain  that  valuable  time 
should  not  be  taken  up  after  the  failure 
of  drugs  if  jaundice  and  fever  are  pres- 
ent, as  the  patient  may  soon  be  beyond 
surgical  help.  The  administration  of 
alkaline  waters,  especially  of  Carlsbad 
salts,  has  been,  in  many  cases,  followed 
by  good  results. 

Naunyn  (quoted  by  Krau.ss)  says: 
"I  have  not  the  slightest  doubt  but  that 
the  Carlsbad  cures  have  the  best  influ- 


ence on  the  course  of  cholelithiasis.  I 
have  seen  a  considerable  number  of  dan- 
gerous gall-stone  incarcerations,  which 
have  lasted  a  long  time,  terminate  favor- 
ably." Krauss  states  that  the  cures  can 
be- taken  at  home  and  should  last  from 
four  to  six  weeks.  A  bottle  of  Carlsbad 
should  be  taken  each  day  as  follows: 
Two  tumblerfuls  in  the  morning  before 
breakfast  warmed  to  140°  or  150°,  at  an 
interval  of  fifteen  minutes.  In  the  even- 
ing one  tumblerful  should  be  taken  cold. 
If  the  water  does  not  produce  a  free 
evacuation  of  the  bowels,  Spriidel  salt 
should  be  given  in  addition.  Krauss 
attaches  great  importance  to  diet.  As  a 
rule,  he  forbids:  fat,  vinegar,  hot  spices, 
pastry;  vegetables,  both  dried  and  un- 
boiled; roasted  potatoes,  and  cheese. 
He  recommends  the  following  diet  in  or- 
dinary cases: — 

Breakfast:  A  cup  of  tea  or  coffee, 
little  milk;  little  sugar,  if  any;  and  two 
or  three  pieces  of  rusk  or  toast,  one  or 
two  soft-boiled  eggs,  or  some  fish  or  cold 
meat. 

Midday  meal:  Fish  (salmon  and  eels 
excepted),  roasted  meat  without  sauce, 
green  boiled  vegetables  or  mashed  pota- 
toes, stewed  fruits  without  sugar.  Drink 
plain  or  slightly-effervescing  water,  red 
wine  (one  or  two  glasses),  or  weak 
whisky. 

Supper:  Cold  or  hot  meat  (fresh 
roasted),  tea,  wine,  or  whisky  (small 
quantities).  He  usually  limits  the  bread 
to  from  four  to  six  ounces  a  day. 

The  use  of  olive-oil  has  still  many  ad- 
vocates. 

Olive-oil  i.s  useful  in  gall-stone,  if 
properly  administered.  Not  more  than 
1  to  2  ounces  may  be  given.  Its  action 
produces  a  watery  flow  from  the  mu- 
cous membrnneH,  and  therefore  helps  to 
increase  the  flow  of  the  normal  duodenal 
secretions,  namely:  the  biliary,  the 
pancreatic,  and  the  secretion  of  Brun- 


CHOLELITHIASIS.     TREATMENT.     .MEDICAL. 


125 


ner's  glands.  Quite  good  results  have 
been  reported.  Indications  for  surgical 
interference  are:  (1)  when  tliere  is  con- 
tinued fever  not  traced  to  other  to.xins; 

(2)  complete  occlusion  of  the  cystic 
duct,  usually  by  a  single  large  calciUus; 

(3)  in  cases  of  chronic  obstructive  jaun- 
dice from  impaction  by  one  or  more  cal- 
culi in  the  common  duct.  W.  H.  Thom- 
son (New  York  Med.  Jour.,  April  19, 
1902). 

As  a  rule,  too  little  water  is  taken  in 
these  cases.  Alkaline  saline  waters 
stimulate  peristalsis  and  increase  the 
flow  of  blood  to  the  abdomen,  the  bile- 
passages  being  massaged  by  the  former 
and  the  diseased  mucous  membrane 
benefiting  by  the  latter.  These  salines 
do  not  dissolve  the  stones,  for  such 
allowed  to  stand  two  weeks  in  a  1-per- 
ccnt.  solution  of  sodium  salicylate,  ben- 
zoate,  phosphate,  sulphate,  bicarbonate, 
or  chloride;  potassium  sulphate,  or 
amraoniimi  chloride  suffered  no  loss  of 
weight.  Allowed  to  stand  in  olive-oil, 
however,  a  gall-stone  lost  G8  per  cent, 
of  its  weight  in  two  days  and  then  dis- 
integrated. The  solid  matter  of  a  stone 
becomes  viscid  in  a  few  hours  in  a  5- 
per-cent.  solution  of  animal  soap.  Large 
doses  of  oil  probably  do  not  reach  the 
gall-stone  directly,  but,  by  producing  an 
increased  proportion  of  fat,  fatty  acid, 
and  soap  in  the  bile,  cause  it  to  have 
a  solvent  action  on  the  choles'terin  of 
the  stone.  For  this  method  of  treat- 
ment from  2  to  10  ounces  of  oil  should 
be  given  daily,  and  the  results  are  very 
questionable.  Massage  of  the  gall-blad- 
der would,  in  many  instances,  be  useless 
or  harmful.  During  a  gall-stone  attack 
relief  is  urgently  demanded.  A  pint  of 
water  taken  as  hot  as  possible,  with  hot 
fomentations  over  the  liver,  may  give 
relief,  or  1  cubic  centimetre  {15  minims) 
of  spiritus  a;thcris  in  2  teaspoonfuls  of 
chloroform-water  every  quarter  of  an 
hour.  Exalgin,  0.06  gramme  (1  grain), 
every  half-hour  for  three  or  four  doses 
is  also  of  service.  These  failing,  mor- 
phine must  be  used.  Mayo  Kobson  (All- 
butt's  "System  of  Medicine";  Medical 
News,  ISIarch  29,  1902). 
In  cases  of  cholecystotomy,  when 
there  is  an  external  biliary  fistula  and 


gall-stones  still  remain  in  the  common 
eholedoeh-duct,  the  injection  of  olive- 
oil  into  the  gall-bladder  has  been  recom- 
mended so  as  to  enable  it  to  directly  ex- 
ert its  solvent  action  on  the  calculi  still 
remaining.  A  case  is  reported  by  Morris 
in  which  a  cure  by  this  means  took  place 
after  six  weeks'  treatment. 

Calomel,  followed  by  salines,  may  be 
of  use  in  emptying  the  gall-bladder  and 
expelling  the  calculi  if  tiiey  are  very 
small. 

Butter  recommended  to  be  taken  in 
large  quantities  instead  of  olive-oil  for 
the  prevention  and  cure  of  gall-stones. 
Fifteen  to  20  grammes  (4  to  6  drachms) 
of  butter  spread  on  biscuits  are  to  be 
given  each  morning.  Felix  von  Oefele 
("Artzliche  Rundschau,"  '90-'97). 

Enemata  of  olive-oil  recommended  for 
the  treatment  of  cholelithiasis.    A  more 
direct  action  on  the  liver  is  obtained  by 
this  mode  of  administration,  while  there 
is  less  danger  of  affecting  the  stomach. 
This  is  an  addition  to  our  present  means 
of    treatment    of    cholelithiasis.     Blume 
("Verhiindlungen  der  Congress  f.  innere 
Med.,"  Wiesbaden,  '97). 
The  most  effective  remedy  for  biliary 
colic  is  an   hypodermic   of   V*   or   Vs 
grain  of  morphine  with  V120  grain  of 
atropine.     Hot  applications  applied  lo- 
cally afford  some  relief,  and  a  weak,  hot 
solution  of  bicarbonate   of  soda  taken 
into  the  stomach  in  large  quantities  haa 
been  recommended. 

Olive-oil  in  from  5-  to  10-ounce  doses 
is  said  to  shorten  an  attack.  Glycerin 
is  also  credited  with  value  when  em- 
ployed in  the  same  manner. 

Surgical  Tre.vtmlxt.  —  Much  has 
been  accomplished  within  the  last  few 
years  in  the  improvement  of  older  meth- 
ods and  in  the  introduction  of  new  plans 
of  operation  on  the  more  difficult  cases 
of  gall-stone  surgery. 

Given  a  reasonable  certainty  of  the 
presence  of  gall-stones  in  the  gall-blad- 
der or  ducts,  it  calls  for  their  removal 


126 


CHOLELITHIASIS.    TKEATMEKT.    SURGICAL. 


by  means  of  the  surgeon's  knife.  Where, 
however,  there  exists  some  disease  of 
other  organs  of  the  body,  as  the  kid- 
neys or  the  heart,  which  would  render 
the  use  of  an  antesthetic  immediately 
dangerous  to  the  health  of  the  indi- 
vidual, it  is  questionable  .whether  oper- 
ation should  be  undertaken.  If  gall- 
stones are  acute  in  their  manifesta- 
tions, it  is  better  to  wait  until  th^ 
symptoms  have  diminished  or  subsided. 
if  attended  with  jaundice,  to  wait  a 
reasonable  time  to  see  if  it  does  not 
diminish;  and,  if  it  does  not,  to  at- 
tempt to  improve  coagulability  of  the 
blood  by  the  use  of  calcium  chloride. 
In  recent  years,  by  means  of  calcium 
chloride,  the  coagulability  of  the  blood 
has  been  increased  or  improved  to  such 
an  extent  as  to  make  a  surgical  oper- 
ation much  less  dangerous  than  before 
it  was  given.  If  there  are  symptoms 
of  gall-stones  in  the  common  duct,  and 
they  have  subsided,  and  if  following 
that,  within  a  reasonable  length  of 
time,  there  are  further  symptoms  or 
indications  of  gall-stones,  operation  is 
indicated.  Frank  Billings  (Annals  of 
Surg.,  Sept.,  1903). 

Cases  have,  from  time  to  time,  been 
reported  in  which  a  diagnosis  of  chole- 
lithiasis had  been  made,  and  when  op- 
erated upon  gall-stones  have  not  been 
found.  In  some  of  these  recovery  has 
taken  place  in  a  remarkable  way. 

The  arguments  in  favor  of  removing 
gall-stones  at  the  earliest  favorable 
moment  after  the  diagnosis  has  been 
made  may  be  summed  up  as  follows: 
The  operation  is,  as  a  rule,  easy  and 
safe  and  all  stones  are  quickly  removed. 
The  remote  dangers  of  gall-stones  are 
eitlier  avoided  or  lessened.  These  are: 
serious  disabilities,  grave  emergencies, 
and  malignant  disease.  If  the  diagnosis 
of  gall-stones  proves  to  be  wrong,  other 
lesions  may  be  discovered  and  remedied: 
lesions  perliaps  more  serious  than  tliose 
of  gall-stones.  Late  operations  upon 
gall-stones  arc,  as  a  rule,  difTicult  and 
dangerous.  Operations  made  imperative 
by  progressive  and  lethal  symptoms 
must  be  performed  under  great  disad- 
vantages and  dangers;    the  gall-stonec 


are  generally  more  inaccessible,  the  dis- 
sections deeper,  and  the  patient's  power 
of  resistance  lessened.  The  arguments 
against  early  operation  are:  There  is 
some  danger  in  the  operation,  though  it 
is  but  slight.  The  diagnosis  may  be 
wrong  and  the  exploration  unnecessary. 
There  is  the  possibility  of  hernia  in  the 
scar.  There  is  the  possibility  that  the 
gall-stones  may  recur.  There  is  the  pos- 
sibility of  spontaneous  cure.  There  is 
also  the  possibility  that,  after  offend- 
ing enough  to  prove  the  diagnosis,  the 
gall-stones  may  give  no  further  trouble. 
The  last  and  decisive  attacks  of  biliary 
colic  may  have  been  caused  by  the  last 
remaining  gall-stone,  exploration  show- 
ing that  none  of  them  remains.  M.  H. 
Eichardson  (Boston  INIed.  and  Surg. 
Jour.,  Sept.  5,  1901). 

In  720  operations  the  mortality  was 
15.5  per  cent.     From  these   operations, 
however,  185  can  be  deducted,  either  on 
account  of  operations  at  the  same  time 
on  the  stomach  or  intestines,  the  pan- 
creas, the  liver,  etc.,  or  because  there 
was   inoperable   carcinoma   of   the  gall- 
bladder,  gall-duct,   or   liver,    or   diffuse 
purulent   nephritis,   peritonitis,   or   cys- 
titis.    This  leaves  535  operations  solely 
for  gall-stones,  with  a  mortality  of  3.5 
per   cent.     It  must   be   remembered   in 
these   statistics   that   all    patients   who 
died   within    one   hundred    days    of   the 
operation  are  included.     Death  in  many 
of  these  cases  cannot  be  ascribed  in  any 
way  to  the  surgeon's  intervention.     In 
tlie  case  of  sepsis  and  carcinoma  with  a 
mortality  of  97  per  cent,  the  operation 
is   justified    because    such    patients    are 
certain   to   die,   and   if   3   per  cent,   are 
saved  it  is  a  considerable  gain.     More- 
over, error  in  diagnosis  sometimes  oc- 
curs, and  it  is  found  at  the  operation 
that  the  condition  is  not  so  severe  as 
was    suspected.     II.    Kehr    (MUnchener 
med.  VVochcn.,  Oct.  28,  1902). 
Henry  Morris  (in  Krauss,  on  "Gall- 
stones") states  that  there  are  several  cases 
on   record   to   prove   that,   where   pain 
alone  or  pain  with  jaundice  has  been 
such  as  to  reduce  patients  to  the  verge 
of    suicide    or    death,    laparotomy    and 
digital  examination  of  the  liver  and  gall- 


CHOLELITHIASIS.    TREATMENT.    SUEGICAL. 


127 


ducts  have  restored  the  sufferer  to  com- 
plete good  health,  though  no  tumor  nor 
gall-stones  have  been  found  to  account 
for  the  symptoms.  Morris  found  adhe- 
sions to  the  abdominal  wall  in  one  case, 
and  in  another  a  general  enlargement  of 
biliary  ducts  from  some  unknown  cause. 
It  is  possible  that  in  some  of  these  cases 
a  gall-stone  in  the  ampulla  of  Vater  may 
be  pushed  through  into  the  duodenum 
during  the  manipulation. 

The  indications  for  operation  in  chole- 
lithiasis are  thus  given  by  Mayo  llob- 
son:  "1.  In  frequently-recurring  biliary 
colic  without  jaundice  with  or  without 
enlargement  of  the  gall-bladder.  2.  In 
enlargement  of  the  gall-bladder  without 
jaundice,  even  unaccompanied  by  great 
pain.  3.  In  persistent  jaundice  ushered 
in  by  pain,  and  where  recurring  pains 
with  or  without  ague-like  paroxysms 
render  it  probable  that  the  cause  is  gall- 
stones in  the  common  bile-ducts.  4.  In 
empyema  of  the  gall-bladder.  5.  In 
peritonitis  starting  in  the  right  hypo- 
chondriac region.  6.  In  abscesses  around 
the  gall-bladder  or  bile-ducts  whether  in, 
under,  or  over  the  liver.  7.  In  some 
cases,  where,  although  the  gall-stones 
may  have  passed,  adhesions  remain  and 
prove  a  source  of  pain  and  illness.  8. 
In  fistuliE:  mucous,  muco-purulent,  or 
biliary.  9.  In  certain  cases  of  jaundice 
with  distended  gall-bladder  dependent 
on  some  obstruction  in  the  common  bile- 
duct.  10.  In  phlegmonous  cholecys- 
titis and  in  gangrene,  if  this  can  be  seen 
and  recognized  at  a  sufficiently-early 
stage  of  the  disease."  (Allbutt's  "Sys- 
tem of  Medicine.")  Kobson  does  not 
approve  of  sounding  for  gall-stones 
through  the  abdominal  walls.  He  also 
condemns  massage  of  the  gall-bladder. 

.'\mong  the  cases  of  gall-stones  not  to 
be  operated  upon  are  those  where  the 
first  paroxysm  of  pain  is  succeeded  by 


all  the  typical  manifestations,  where  the 
patient  becomes  jaundiced  on  the  sec- 
ond to  third  day  and  passes  small  stones 
by  the  natural  way.  Repeated  attacks 
are  not  indications  for  operations  when 
each  time  small  stones  are  passed. 
When  there  are  numerous  attacks  with- 
out the  passage  of  small  stones  then 
the  question  of  operation  arises  on  ac- 
count of  the  suspicion  that,  besides  the 
small  calculi,  there  may  also  be  large 
ones  impacted  in  the  gall-bladder. 
Those  eases  should  not  be  operated 
upon  in  which  after  repeated  ineflfectual 
attacks  larger  calculi  have  been  passed, 
for  if  a  large  stone  has  been  passed 
others  may  follow.  If  ineffectual  at- 
tacks continue  to  follow,  an  operation 
is  indicated.  But  a  single  ineffectual 
attack,  without  jaundice,  indicates 
operation.  A  state  of  latency  may  be 
partially  at  times  brought  about  by 
aperients,  but  it  is  of  short  duration. 
Operation  is  indicated  in  those  cases 
where,  after  repeated  ineffectual  attacks, 
the  uppermost  stone  enters  and  becomes 
impacted  in  the  ductus  choledochus. 
This  impaction  must  be  determined  by 
waiting,  two  to  three  weeks  being  suflS- 
cient.  Riedel  (Berliner  klin,  Woch., 
Jan.  21,  1901). 

In  one-third  of  the  cases  the  symp- 
toms were  of  ten  years'  or  more  dura- 
tion. In  less  than  one-fourth  the  symp- 
toms had  persisted  for  less  than  two 
years.  Cholecystenterostomy  is  a  make- 
shift at  the  best ;  the  cystic  duct  may 
not  be  patent.  Expression  of  the  stone 
into  the  duodenum  or  bladder  is  not 
easy.  No  cases  have  been  operated  upon 
by  the  transduodenal  route.  Crushing 
of  the  stone  leaves  debris.  In  none  of 
the  above  methods  can  it  be  determined 
whether  or  not  the  ducts  are  patulous. 
In  six  of  the  cases  only  one  stone  was 
found.  For  the  relief  of  the  late  des- 
perate cases  a  rapid  cholecystotomy  may 
be  made.  The  method  of  choice  consists 
in  incising  the  duct,  removing  the  stone, 
suturing  the  duct,  and  draining  the  gall- 
bladder. This  procedure  was  carried  out 
in  21  of  the  cases  without  a  death.  M. 
B.  Tinker  (Phila.  Med.  Jour.,  June  21, 
1902). 

As   soon    as   gall-stones    give   serious 


128 


CHOLEUTHIASIS.    TEEATMENT.    SURGICAL. 


trouble,  operation  is  indicated,  for  it  is 
onlj'  from  the  complications  which  in 
many  cases  arise  sooner  or  later  that 
any  danger  after  operation  need  be  ap- 
prehended. Medical  treatment  may  do 
much  to  relieve  the  catarrh  associated 
with  cholelithiasis,  but  no  medicine  can 
dissolve  gall-stones  or  produce  perma- 
nent relief.  It  is  impossible  to  say  what 
operation  will  have  to  be  done  imtil  the 
abdomen  is  opened  and  the  exact  state 
of  affairs  made  out. 

No  surgeon  shoiild  attempt  the  re- 
moval of  gall-stones  unless  he  is  pre- 
pared to  perform  any  of  the  various  op- 
erations on  the  biliary  passages,  and  no 
operation  should  be  concluded  until  it  is 
determined  that  the  ducts,  including  the 
hepatic  and  common,  are  free  from  con- 
cretions, otherwise  dissatisfaction  is  cer- 
tain to  follow.  A  gall-stone  scoop  is  the 
only  special  appliance  that  need  be  em- 
ployed. Rubber  gloves  impair  the  sense 
of  touch  and  cause  delay.  In  jaundiced 
patients  calcium  chloride  is  given  in  30- 
grain  (2  grammes)  doses  by  mouth  be- 
fore operation  and  afterward  in  60-grain 
(4  grammes)  doses  by  rectum,  thrice 
daily  for  two  or  three  days  or  longer  if 
necessary. 

A  sandbag,  placed  under  the  patient 
at  the  level  of  the  liver,  will  push  the 
spine  forward  and  with  it  the  liver  and 
bile-ducts;  so  that  the  common  and 
hepatic  ducts  are  brought  several  inches 
nearer  the  surface.  The  writer  always 
makes  his  incisions  over  the  middle  of 
the  right  rectus  and  in  line  parallel 
with  its  fibres,  which  are  separated  by 
the  finger.  If  more  room  is  required, 
the  incision  is  carried  upward  in  the 
interval  between  the  ensiform  cartilage 
and  the  right  costal  margin  as  high  as 
posBible.  By  lifting  the  lower  border  of 
the  liver,  first  drawing  the  organ  down- 
ward from  under  the  cover  of  the  ribs, 
the  whole  of  the  gall-bladder  and  the 
cystic  and  common  ducts  are  brouglit 
to  the  surface.  An  assistant  gently 
draws  the  gall-bladder  upward  with  one 
hand  and  retracts  the  left  side  of  tlie 
wound  and  the  viscera  with  the  other. 
The  gallbladder,  cystic  and  common 
ductB  now  form  a  straight  passage  from 
the  fundus   of  the  gall-bladder   to   the 


duodenum,  and  the  wliole  length  of  the 
ducts,  with  the  duodenimi  and  liead  of 
the  pancreas,  are  in  view.  Stones  in  the 
ducts  are  detected  by  palpation  and  re- 
moved by  incision  into  the  ducts.  If 
the  common  duct  has  been  incised,  a 
probe  may  be  passed  into  the  hepatic 
duct  and  down  the  common  duct  into 
the  duodenum.  The  incision  into  a  bile- 
duet  is  closed  by  a  ciu-ved  needle  held 
in  the  fingers  without  a  needle-holder, 
a  continuous  catgut  suture  being  used 
for  the  margin  of  the  duct  proper,  and 
a  continuous  catgut  or  celluloid  thread 
being  employed  to  close  the  peritoneal 
edges  of  the  duct.  When  the  gall-blad- 
der is  contracted  and  a  swollen  pancreas 
presses  on  the  common  duct,  a  drainage 
tube  is  inserted  into  the  hepatic  duct, 
passing  upward  through  the  common 
duct,  and  here  held  by  a  catgut  stitch. 
Prolonged  manipulations  are  never  made 
on  a  stone  deeply  impacted  even  in  the 
cystic  duct,  but  the  duet  is  at  once 
incised  and  the  concretion  removed. 
Drainage  is  effected  by  gauze  surroxuided 
with  a  split  drainage  tube,  which  is 
brought  out  by  the  side  of  the  gall- 
bladder drain.  All  bleeding  points  and 
all  firm  adhesions  are  ligated.  Ideal 
cholecystotomy  (cholecystotomy  in  two 
stages)  and  partial  cholecystectomy 
(Mayo)  are  not  regarded  with  favor. 
A  contracted  gall-bladder  which  caimot 
be  brought  to  the  surface  may  be 
drained  by  fixing  a  tube  into  it  with 
a  purse-string  suture,  the  general  peri- 
toneal cavity  being  protected  by  gauze 
packing.  In  many  of  these  cases  it  is 
better  to  remove  the  gall-bladder.  If  a 
stone  is  impacted  in  the  duodenal  ends, 
a  duodeno-choledoehotomy  is  sometimes 
the  easiest  operation.  A  cholecysten- 
terostomy  is  rarely  used  because  the 
trouble  is  not  removed;  when  it  is  nec- 
essary it  will  be  found  easier  to  anas- 
tomose the  gall-bladder  with  the  colon. 
In  detaching  adhesions  a  careful  search 
m\iHt  always  be  made  for  an  opening 
into  the  hollow  viscera.  A.  W.  Mayo 
Robson  (British  Medical  Journal,  Jan. 
24,  1903). 

ChohcysloLomy    is    the    operation    of 
choice  in  cholelithiasis,  and  it  is  consid- 


CHOLELITHIASIS.    TREATMENT.     SURGICAL. 


129 


Kg.  1. — The  pouch  described  shown  by  draw- 
ing  liver   upward.     X    in    all    the    figures      ^"'e-  3.-Transverse  section  through  centre  of 
marks  point  for  drainage.  poucn. 


Fig.  2. — Vertical  mesial  section. 


Fig.  4.— Fouch  (X)  behind  the  right  lobe  of 
the  liver  having  natural  barricades  from  the 
general  peritoneal  cavity. 

Posterior  hepatic  pouch,     {ilorison.) 

(British  MediMl  JoiirnitlJ 


130 


CHOLELITHIASIS.    TREATMENT.    SURGICAL. 


ered  safer,  after  opening  the  gall-blad- 
der, removing  the  calculi,  and  ascertain- 
ing that  the  biliary  passages  are  clear, 
to  suture  the  walls  of  the  gall-bladder  to 
the  edges  of  the  wound  than  to  perform 
the  so-called  '"ideal"  operation  of  sutur- 
ing the  opening  in  the  gall-bladder  and 
returning  it  into  the  abdomen.  It  is 
better  to  suture  to  the  aponeurotic  layer 
of  the  abdominal  wall  and  not  to  the 
skin.  Mayo  Eobson  prefers,  when  there 
is  time,  to  stitch  the  peritoneal  layer  of 
the  gall-bladder  to  the  parietal  perito- 
neum and  the  mucous  layer  to  the  apo- 
neurosis. A  drainage-tube  is  then  in- 
serted. 

When  a  fistulous  opening  is  left,  cal- 
culi not  removed  at  the  operation  may 
find  an  exit.  When  the  incised  gall- 
bladder is  returned  to  the  abdominal 
cavity  leakage  may  take  place. 

When  the  gall-bladder  is  contracted 
and  cannot  be  brought  to  the  edge  of 
the  wound.  Mayo  Robson  sometimes 
tucks  down  the  parietal  peritoneum  to 
the  gall-bladder  and  sutures  it  to  the 
edge  of  the  incision.  When  he  cannot 
do  this,  he  utilizes  the  right  border  of 
the  omentum  by  suturing  it  to  the  gall- 
bladder opening  and  to  the  parietal  peri- 
toneum around  the  drainage-tube  and 
shutting  out  the  general  peritoneal  cav- 
ity. If  neither  of  these  methods  can 
be  adopted,  he  passes  a  drainage-tube 
through  the  opening  into  the  gall-blad- 
der and  plastic  peritonitis  shuts  off  the 
general  peritoneal  cavity.  The  tube  is 
sometimes  packed  around  with  gauze. 
He  prefers  to  drain  the  peritoneal  cavity 
by  passing  a  tulje  into  the  right  kidney- 
pouch  through  the  original  abdominal 
incision  or  through  an  opening  in  the 
side  of  the  abdomen. 

A  flHtula  does  not  eloHC  because  the 
mueouH  membrane  in  sewed  to  the  skin, 
but  it  does  close  when  united  to  the  cut 


edges  of  the  peritoneum  and  transversalia 
fascia.  Perkins  (Boston  Med.  and  Surg. 
Jour.,  Jan.  25,  '94). 

In  cases  of  obstruction  of  the  common 
duct,  no  attempt  should  be  made  to 
suture  the  opening  after  the  obstruc- 
tion has  been  removed,  as  the  patient's 
condition  is  nearly  always  serious  and 
a  prolonged  operation  would  terminate 
fatally.  The  obstruction  should  always 
be  removed,  if  possible.  Experiments 
demonstrating  that  the  peritoneum  is 
capable  of  bearing  the  presence  of  a 
small  amount  of  bile,  but  that  large 
quantities  or  the  constant  extravasation 
of  it  would  produce  a  fatal  peritonitis, 
usually  In  from  twenty-four  to  forty- 
eight  hours.  W.  E.  B.  Davis  (N.  Y.  Med. 
Jour.,  Oct.  26,  '95). 

Case  of  biliary  obstruction  complicated 
by  peritoneal  adhesions.  A  first  incision 
was  made  in  a  line  of  and  down  to  a  dis- 
tended gall-bladder.  A  second  incision 
was  made  in  the  right  flank  and  about 
a  pint  of  fffitid  and  bile-stained  pus 
was  evacuated.  The  abscess-cavity  was 
bounded  above  by  the  liver,  behind  by 
the  colon,  the  distended  gall-bladder  on 
inner  and  parietal  peritoneum  on  the 
outer  side.  Ten  ounces  of  healthy  bile 
and  forty-three  gall-stones  were  removed 
from  the  distended  gall-bladder.  W.  F. 
Brook  (British  Medical  Journal,  Feb.  5, 
•98). 

As  results  of  27  operations  on  cases  of 
gall-stones,  the  following  conclusions  are 
reached:  I.  Tait's  operation  of  simple 
cholecystotomy  with  drainage  of  the 
gall-bladder  is  the  ideal  operation  in 
most  cases.  2.  Incision  of  the  common 
and  cystic  ducts  is  the  safest  and  most 
surgical  means  of  removing  stones  in 
them.  S.  Excision  of  the  gall-bladdrr 
may  find  a  wider  field  than  heretofore. 
4.  McHurney  has  shown  that  incision  of 
the  duodenum,  and  either  dilatation  or 
incision  of  the  common  duct  through  this 
incision,  is,  in  skilled  hands,  both  eriicient 
and  safe  for  the  removal  of  stones  low 
down  in  tlie  coinnion  duct.  In  neglected 
cases  with  dense  and  many  adhesions  and 
dilated  stomach,  an  additional  gastro- 
enterostomy or  pyloroplasty  will  save 
cases  which  would  otherwise  die.  5.  The 
mortality   of   the   simple   cases   is   prac- 


CHOLELITHIASIS.    TREATMENT.     SURGICAL. 


131 


tically  nil.  W.  VV.  Seymour  (Amer. 
Jour,  of  Obstct,  Nov.,  '99). 
Choledoclwiomy. — Much  attention  has 
been  given  within  the  last  three  or  four 
years  to  the  improvement  of  this  opera- 
tion, and,  although  in  many  cases  diffi- 
cult, it  can  be  performed  with  greater 
safety  to  the  patient  than  formerly.  The 
suturing  of  the  incised  walls  can  be 
much  more  easily  and  completely  done, 
and  leakage  to  a  very  great  extent  pre- 
vented. 

With  our  present  experience  and  tech- 
nique we  may  safely  say  that  choledo- 
ehotomy,  in  the  majority  of  oases,  is  a 
diflicult  and  tedious  operation  wliich  may 
tax  to  the  utmost  the  resources  of  the 
patient,  but  its  results  usually  are  emi- 
nently favorable.  Jaundice  should  not 
be  allowed  to  exist  too  long.  Let  me 
emphasize  once  more  that  preservation 
of  life  and  health  in  many  cases  depends 
upon  the  proper  time  being  chosen  for 
surgical  interference.  Lange  (Med. 
News,  May,  '97). 

In  many  instances  biliary  calculi  may 
be  removed  from  the  common  bile-duct 
through  an  incision  in  the  anterior  wall 
of  the  descending  duodenum.  This  is  an 
exceptionally  good  route,  if  the  calculus 
be  situated  in  the  lower  third  of  the  com- 
mon duct.  The  orifice  of  the  duct  may, 
if  necessary,  be  incised  for  one-half  inch, 
with  perfect  safety,  and  the  duct  itself 
is  easily  dilated.  Method  employed  on 
si.x  different  occasions,  and  in  each 
instance  the  intestinal  wound  healed 
kindly.  Charles  McBurney  (Annals  of 
Surg.,  Oct.,  '98). 

One  of  two  incisions  should  be  em- 
ployed in  exploring  the  region  of  the  gall- 
bladder or  bile-ducts;  the  best  one  ex- 
tends from  about  V:  inch  below  the  free 
border  of  the  costal  cartilages  to  a  point 
2  or  .S  inches  above  the  umbilicus,  pass- 
ing just  within  the  outer  border  of  the 
rectus  muscle.  The  second  is  a  curved 
incision  parallel  with  the  free  border  of 
the  costal  cartilages  and  about  1  inch 
below  them. 

None  but  the  ninth  dorsal  nerve  will 
have  been  divided  by  either  of  the  two 
incisions  as  described.    The  longitudinal 


one  is  to  be  preferred.    If  the  gall-stone 
be  lodged  in  the  gall-bladder  the  calculi 
are  removed  from  an  incision  in  the  fun- 
dus of  the  gall-bladder  after  the  latter 
lias  been  stitched  to  the  abdominal  wall. 
In  order  to  avoid  annoyance  of  a  fistula's 
persisting   for   weeks    or   months    after 
operation,  McBurney  recommends  follow- 
ing modification  of  ordinary  procedure: 
The  circumference  of  gall-bladder  about 
one-half  inch  below  fundus  is  sutured  to 
the  edges  of  abdominal  wound;  a  purse- 
string  suture  is  passed  around  gall-blad- 
der between  opening  in  fundus  and  line 
of  suture  to  abdominal  wall;    the  free 
edge  of  incised  fundus  is  now  inverted,  a 
small  rubber  drainage-tube   is  inserted, 
and  the  purse-string  is  tightened,  so  as 
to  prevent  reversion  of  inverted  edges. 
After  tliis  method  the  drainage-tube  may 
be  removed  in  the  course  of  several  days 
and  in  a  short  while  the  fistula  will  be 
permanently  closed.     C.  McBurney  and 
H.  T>.  Collins  (Med.  News,  Nov.  26,  '98). 
Dr.  W.  S.  Halsted,  in  an  article  in 
Johns  Hopkins  Hospital  Bulletin,  April, 
1898,  on  the  use  of  small  hammers  and 
the  suture  of  the  bile-ducts,  commences 
as  follows:    "The  surgery  of  common 
bile-ducts  is  still  in  its  infancy.    'Suture 
of  the  thickened  duct  is  difficult  enough 
and  suture  of  the  normal  duct  is  out  of 
the  question,'  saj's  one.    'It  is  not  worth 
while  to  exercise  great  care  in  sewing  up 
a  slit  in  the  common  bile-duct,  for  it  is 
almost   impossible   to   prevent   leakage, 
and  a  little  additional  leakage  can  do  no 
harm  if  one  drains,'  says  another.    'Wait 
until    the    common    duct    dilates    and 
thickens  before  venturing  to  open  it,'  say 
all  surgeons." 

Halsted  states  that  he  has  ascertained 
from  operations  on  dogs  and  man  that 
the  normal  bile-ducts  can  be  sutured 
easily,  accurately,  almost  infallibly,  and 
without  danger  of  leakage  or  constric- 
tion. He  approves  of  Lange's  suggestion 
to  cut  through  one  or  two  ribs  and  the 
diaphragm,  if  it  is  necessary  thus  to 
render  the  parts  operated  upon  more  ac- 


132 


CHOLELITHIASIS.    TREATMENT.    SURGICAL. 


cessible.  He  then  describes  small  ham- 
mers, the  heads  of  which,  being  of  vari- 
ous sizes,  he  inserts  into  the  common 
duct,  after  the  incision  has  been  made 
and  the  stone  removed.  The  contents 
are  thus  prevented  from  escaping,  and 
the  duct  can  be  raised  or  lowered  at  will 
by  the  operator.  The  wall  is  more 
easily  sutured  over  the  head  of  the  ham- 
mer. He  has  a  series  of  hammers  which 
he  attaches  to  a  long  handle,  using  one 
of  proper  size  to  easily  enter  the  duct. 
The  method  is  graphically  shown  in  the 
annexed  colored  plate,  while  the  ham- 
mer and  the  various  diameters  of  the 
latter  employed  are  illustrated  here. 

Series  of  209  laparotomies  for  gall- 
stones with  special  reference  to  30  cases 
of  clioledochotomy.  He  classifies  his 
operations  into  five  groups: — 

1.  Those  in  which  the  stone  is  found 
in  the  gall-bladder  or  cystic  duct;  97 
one-sided  and  3  double-sided  cholecys- 
totomies,  4  cystendysis  and  23  cystecto- 
mies. Altogether  127  gall-bladder  opera- 
tions with  but  1  death. 

2.  Two  cystectomies  and  1  death. 

3.  Stone  iTi  choledoch-duct  which  could 
not  be  moved  into  the  gall-bladder  or  duo- 
denum;   30  eholedochotomics,  2  deaths. 

4.  Seventeen  cases  with  dense  adhe- 
sions, fistula,  etc. 

5.  Cases  complicated  by  carcinoma  and 
other  conditions  necessarily  fatal  in  the 
end. 

The  mortality  bore  a  definite  relation- 
ship to  the  pathological  conditions  pres- 
ent. In  the  209  laparotomies  there  were 
17  deaths,  being  8  per  cent.;  but  the 
mortality  was  reduced  to  a  minimum  in 
the  case  of  stones  on  the  gall-bladder 
and  cystic  ducts,  while  it  reached  0  per 
cent,  when  there  were  changes  in  the 
gall-bladder  which  demanded  cholecys- 
tectomy. Suppurative  cholangitis  proved 
a  very  fatal  condition.  EmphasiH  laid 
upon  the  following  three  points,  viz.:  ac- 
curacy in  the  diagnosis  of  gall-stones,  a. 
thorough  knowledge  of  the  pathology  of 
the  disease,  and  perfection  in  the  tech- 
nique   of    the    operation.      Hans    Kehr 


("Verhiindlungen  der  deut.  Gesellschaft 
f .  Chir.,"  XXV  Congress,  '96) . 


Hammers  employed  in  suturing  the 
bladder.     (Ualstei.) 


r/m'u/. 


/7y.. 


Suture  of  the  Bile,  Ducts  (Halsted 

JOHNS    HOPKINS    HOSPITAL    BULLtTIN 


CHOLELITHIASIS.    TREATMENT.    SURGICAL. 


133 


Cases  of  cholelithiasis  treated  in  the 
St.  Hedwig  Hospital  at  Berlin  during  ten 
years  analyzed.  Of  these  cases  89  were 
treated  in  the  medical  and  43  in  the 
surgical  wards.  Fifty-seven  of  the  med- 
ically treated  were  traced  and  it  was 
found  that,  after  from  1  to  2  years,  13 
patients  still  suffered;  after  from  3  to 
4  years,  5;  and  after  from  5  to  8  years, 
5.  Twenty-two,  or  41.5  per  cent.,  were 
cured,  4  had  to  be  operated  upon  subse- 
quently, and  4  died.  The  results  of  sur- 
gical treatment  showed  the  mortality 
12.5  per  cent.;  but  when  the  cases  in 
which  death  was  due  to  causes  inde- 
pendent of  the  operation  were  deducted, 
the  remaining  mortality  was  only  2  per 
cent.  In  none  of  the  eases  was  there  a 
return  of  stone-formation  or  of  colic. 
Two  cases  suffered  from  cramps  which 
■were  probably  connected  with  disturb- 
ance in  the  coeliac  ganglia  and  the 
abdominal  sympathetic.  H.  Scheuer 
(Miinchener  med.  Woch.,  June  12,  1900). 

Cholecj'stotomy,  in  which  the  gall- 
bladder is  immediately  sutured  after 
removing  calculi,  has  come  to  be  re- 
garded with  such  universal  disfavor 
that  it  no  longer  has  any  place  in  the 
surgery  of  the  gall-bladder.  On  the 
contrary,  cholecystectomy,  by  which  tho 
fntm  ct  orign  mali  is  destroj-ed  at  a 
single  blow,  is  being  much  more  fre- 
quently performed,  and  is,  indeed,  ad- 
vocated by  some  as  a  routine  pro- 
cedure, just  as  they  would  advise  ex- 
tirpation of  the  appendix.  The  ad- 
vantages of  cholecystectomy  are:  (1) 
The  wound  heals  immediately,  and  the 
liability  to  subsequent  hernia  is  there- 
fore slight;  (2)  there  is  no  possibility 
of  stones  forming  in  the  gall-bladder; 
(3)  subsequent  cholecystitis  cannot  oc- 
cur; (4)  the  formation  of  adhesions  is 
reduced  to  a  minimum;  and  (."))  there  is 
no  possibility  of  malignant  growths 
starting  in  the  gall-bladder.  The  chief 
disadvantages  are:  (1)  It  is  impossible 
to  drain  the  bile-passages  except 
through  one  of  the  ducts,  and  that 
only  after  a  difficult  and  usually  un- 
satisfactory operation;  (2)  there  is 
greater  danger  in  the  operation  itself; 
and  (3)  redrainage  of  the  biliary  pass- 
ages is  extremely  difficult  and   danger- 


ous, should  it  be  subsequently  required. 
M.  II.  Richardson  (Medical  News,  May 
2,  1903). 

Morris  mentions  a  case  in  which,  after 
opening  the  gall-bladder  and  removing 
calculi,  stones  were  found  in  the  com- 
mon duct  which  could  not  be  removed. 
During  the  convalescence  olive-oil  was 
daily  injected  through  the  fistulous 
opening.  In  six  or  eight  weeks  the  pas- 
sage became  patent  and  the  patient  made 
a  good  recovery. 

[Result  of  anastomosis  of  the  gall- 
bladder with  the  colon.  J.  F.  W.  Ross 
reports  a  case  operated  on  in  February, 
1896,  as  still  in  excellent  health.  The 
patient  was  suffering  from  a  gall-stone 
impacted  in  the  common  bile-duct,  pro- 
ducing intense  jaundice.  At  the  time  of 
the  operation  the  adhesions  were  so  great 
that  it  was  impossible  to  isolate  the  com- 
mon duct.  The  liver  was  torn  in  an  at- 
tempt to  accomplish  this.  As  a  conse- 
quence, an  anastomosis  was  produced  be- 
tween the  gall-bladder  and  the  colon  by 
means  of  a  small  Murphy  button.  The 
button  was  passed  about  the  sixteenth 
or  seventeenth  day  after  operation.  The 
jaundice  rapidly  disappeared  and  the 
patient  soon  regained  his  health.  He 
was  seen  a  month  ago  in  perfect  health. 
The  fact  that  the  bile  was  side-tracked 
into  the  colon  had  no  visible  ill  effect. 

Ross  also  reports  having  found  gall- 
stones lying  in  the  common  and  hepatic 
duct,  one  beside  the  other  like  a  row  of 
cobble-stones.  The  stones  in  the  hepatic 
duct  were  found  far  up  to  the  end  of  the 
duct.  They  were  removed  by  a  milking 
process.  In  the  first  place,  a  silk  suture 
was  placed  like  a  running  string  on  the 
wall  of  the  duct.  This  was  put  in  posi- 
tion before  the  duct  was  incised,  so  that 
by  pulling  on  it  like  a  purse-string  the 
orifice  could  be  readily  closed  and  the 
bile  kept  from  welling  into  the  field  of 
the  operation.  If  the  duct  is  incised  first, 
the  bile  welling  out  through  the  orifice 
obscures  the  view.  He  has  adopted  this 
method  of  procedure  on  several  occa- 
sions, and  finds  it  of  great  service. 

After  the  suture  was  placed  he  then 
made  an  incision  into  the  common  duct 


134 


CHOLERA  ASIATICA.     ORIGIN  AND  TRANSJUSSION. 


inside  the  oval  formed  by  the  suture. 
With  the  index  finger  of  the  left  hand  on 
one  side  of  the  duct  and  the  index  finger 
of  the  right  hand  on  the  other  side,  the 
stones  were  gradually  squeezed  down 
from  the  hepatic  duet  and  up  from  the 
intestinal  end  of  the  common  duct  to  the 
opening  just  made  and  pressed  out 
through  it.  In  this  way  ten  or  twelve 
stones  were  removed.  As  the  gall-blad- 
der had  been  previously  opened  and 
three  stones  removed  from  the  interior 
of  the  gall-bladder,  it  was  deemed  ad- 
visable to  stitch  the  gall-bladder  to  the 
abdominal  wall  and  place  a  drainage- 
tube  in  its  interior.  The  patient  made 
an  uninterrupted  recovery  and  has 
since  enjoyed  excellent  health.  J.  E. 
Graham.] 
J.  E.  Graham  (Toronto)  and 
Central  Staff   (Philadelphia). 

CHOLERA  ASIATICA. 

Definition. — Cholera  Asiatica  is  a  mi- 
asmatic, contagious  disease  transmitted 
mainlj'  by  human  intercourse,  but  whose 
epidemic  character  depends  upon  out- 
side conditions. 

Origin  and  Transmission. — The  origi- 
nal seat  of  cholera  is  in  India,  where  it 
most  probably  existed  long  before  this 
century.  In  some  parts,  especially  on  the 
borders  of  the  Ganges  it  is  always  en- 
demic, being  produced  and  entertained 
by  special  conditions  of  the  soil,  by  the 
infection  of  the  water,  etc.,  and  often 
giving  rise  to  epidemic  outbreaks  under 
the  influence  of  high  temperature, 
climatic  variations,  bad  hygienic  condi- 
tions, certain  winds,  etc.  The  epidemics 
may  propagate  themselves  either  by  land 
or  by  sea,  through  the  great  roads  of 
commerce,  being  conveyed  to  other  coun- 
tries by  caravans  or  by  vessels,  forming 
here  and  there  many  momentary,  sec- 
ondary centres.  The  agents  of  trans- 
mission are  persons  infected  with  cholera 
or    specific    diarrhcea,    and    the    linen, 


clothes,  etc.,  soiled  with  choleraic  dejec- 
tions, from  such  persons. 

The  land-route  was  followed  by  the 
first  great  epidemic  of  1S30  and  1848 
(the  last  reaching  America),  while  the 
second  prevailed  in  the  epidemic  of  1869 
and  of  188-1.  When  the  cholera  pro- 
ceeded by  land,  its  course  was  slow  and 
its  steps  easily  marked,  by  its  invading 
successively  Afghanistan,  Persia,  the 
Caspian  shores,  Astrakan,  Russia,  and 
then  turning  toward  the  west  of  Europe 
and  America.  The  epidemics  trans- 
mitted by  sea  generally  made  their  first 
appearance  at  Mecca  or  other  parts  of  the 
Ked  Sea,  and  thence  were  propagated 
to  Egypt,  or  reached  Beyrouth,  Constan- 
tinople, Marseilles,  Toulon,  Naples,  etc., 
each  of  these  places  becoming  a  new 
starting-point  for  the  infection. 

Countries  spared  by  this  scourge  are 
exactly  those  places  out  of  such  com- 
mercial roads,  as  are  the  islands  of  the 
north  of  Europe,  Faroe,  Hebrides,  Ice- 
land and  Greenland,  Baffin  and  Hudson 
Bays,  Patagonia,  western  America,  Poly- 
nesia, Australia,  central  Africa,  etc. 

For  several  epidemics — those  of  1852 
and  of  1859  in  Europe  afEordcd  a 
striking  example,  for  instance — a  direct 
transmission  of  cholera  from  India  could 
not  be  traced;  so  that  they  must  be  at- 
tributed to  a  local  revival  of  the  cholera 
germ,  with  all  its  primitive  attributes, 
in  places  where  it  had  previously  been 
carried  from  India.  It  seems,  therefore, 
that  cholera  germs  of  former  epidemics 
may  live  as  saprophytes  and  wait  until 
conditions  arise,  when  they  again  become 
virulent. 

The  germs  of  cholera,  when  brought 
into  some  places,  there  to  give  rise  to  an 
epidemic  of  cholera,  must  find  local  con- 
ditions favorable  to  their  development. 
Low,  damp,  marshy  lands,  large  towns 
with  crowded  populations,  narrow,  dirty 


CHOLERA  ASIATICA.    ORIGIN  AND  TRAKS]VnSSION. 


135 


streets  and  generally  every  place  in 
which  the  sanitary  conditions  are  very 
imperfect  and  the  inhabitants  very  poor 
are  always  the  first  and  main  centres  of 
the  disease. 

Decaying  vegetable  and  animal  mat- 
ter, bad  drainage,  and  overcrowding  are 
as  much  responsible  for  cholera  as  bad 
drinking-water.  The  regular  removal  of 
faecal  matter  and  efficient  surface-  and 
subsoil-  drainage  will  reduce  the  chance 
of  introducing  cholera  into  a  town  to  a 
minimum.  l!ai  B.  A.  Mitra  (Indian  Med. 
Ecc,  Feb.  15,  '93). 

Koch's  vibrios  traced  to  farm-yard  ma- 
nure, pigs'  faeces  being  found  to  contain 
them.  Nevertheless  there  had  been  no 
cholera  for  years  in  the  region.  Kutscher 
(Zeit.  f.  Hygiene  u.  Infectionskr.,  B.  19, 
p.  461,  '95). 

According  to  Pettenkofer,  indeed,  the 
most  important  part  in  the  development 
of  cholera  is  played  by  certain  geological 
conditions  of  the  soil  (especially  porosity 
and  dampness),  and  by  the  variations  in 
the  level  of  the  ground-water;  so  that  if 
such  a  soil  become  infected  by  choleraic 
germs,  finding  in  it  the  best  conditions 
for  their  growth,  and,  gaining  there 
their  virulent  properties,  the  disease 
diminishes  when  the  ground-water  is 
high,  and  increases  when  its  level  sinks. 

Investigations  on  78  choleraic  patients 
at  the  HOpital  Beaujon.  In  67  cases  the 
comma  bacillus  was  isolated.  During 
the  epidemic  the  virulence  of  the  micro- 
organism had  diminished,  for,  in  order  to 
kill  a  guinea-pig.  a  much  larger  dose  of  a 
culture  isolated  in  September,  1S92,  was 
needed  than  of  that  isolated  in  April  of 
the  same  year.  Girode  (Comptes-rendus 
Hebd.  des  Stances  et  Mem.  de  la  Soc.  de 
Biol.,  Oct.,  '92). 

Study  of  251  cases  of  cholera,  in  no 
one  of  which  was  the  spirillum  fo\md, 
but  always  mixed  with  one  or  more 
bacteria  of  other  kinds.  Lesage  and 
Macaigne  (Ann.  de  I'lnst.  Pasteur,  Jan., 
'93). 

Kvcn  by  the  various  methods  recom- 


mended by  Koch  for  the  recognition  of 
the  cholera  bacillus,  and,  with  the  great- 
est care  and  the  mostaccurate  knowledge 
of  the  subject,  it  is  often  Impossible  to 
come  to  a  positive  result.  The  cause  of 
the  disease  is  not  the  common  bacillus, 
but  some  unknown  noxious  principle.  0. 
Liebreich  (Berl.  klin.  Woch.,  No.  28, '93). 

Personal  experiments  carried  out  with 
a  view  to  determine  the  specificity  of  the 
choleraic  bacillus.  A  sufficient  quantity 
of  the  micro-organism  swallowed  to  give 
rise  to  the  disease,  and  practically  nega- 
tive results  obtained.  This  invalidates 
the  principle  of  specificity  ascribed  to 
the  pathogenic  microbe,  and  tends  to 
prove  that  it  is  not  constantly  virulent 
and  able  invariably  to  give  rise  to 
cholera.      (Pettenkofer  and  Emmerich.) 

Pettenkofer's  experiment  repeated 
without  injury.  At  first  the  experiment- 
ers took  only  small  amounts  of  choleraic 
cultures  without  result,  then  they  took 
larger  amounts,  and  one  of  them  ate  an 
entire  culture  of  a  third  generation.  In 
this  case  in  thirty-six  hours  came  pain 
in  the  bowels,  tenesmus,  and  diarrhoea 
without  particular  characteristics.  In 
one  other  experiment,  in  which  not  a 
sign  of  sickness  occurred,  the  cholera  ba- 
cillus was  found  in  the  normal  dejec- 
tions. Hasterlik  (Corres.  f.  Schweizer 
Acrzte,  Apr.  1,  '93). 

Such  experiments  prove  nothing.  Ev- 
eryone who  has  lived  through  an  epi- 
demic of  cholera  knows  that  there 
always  are  a  large  number  of  slight 
cases.  Such  mild  cases  are  really  cholera, 
as  it  can  be  shown  that  the  dejections 
contain  large  quantities  of  comma 
bacilli.  Guttmann  (Med.  Press  and  Cir- 
cular, Jan.  25,  '93). 

While  accepting  the  comma  bacillus  as 
the  etiological  factor  of  Asiatic  cholera, 
its  presence  in  the  intestine  necessarily 
leads  to  the  development  of  cholera  or  a 
cholera-like  disease.  The  presence  of 
comma  bacilli  in  apparently  healthy 
persons  suggests  that  the  bacilli  may 
temporarily  or  permanently  lose  their 
virulence.  Rumpf  (Centralb.  f.  klin. 
Med.,  No.  25,  p.  2, '93). 

Lesions  of  cholera  produced  by  giving 
intravenous  injections  of  cholera  bacilli, 


136 


CHOLERA  ASIATICA.     ORIGIN  AND  TRANSMISSION. 


pure  cultures  being  obtained  from  the 
faeces.  If  the  animal  received  doses  of 
absolute  alcohol  for  two  days  before  the 
injections,  the  predisposition  to  the 
cholera  infection  was  very  greatly  In- 
creased. Thomas  (Archly  f.  exper.  Path, 
u.  Pharm.,  vol.  xxii,  No.  1,  '94). 

Experiments  showing  that  the  activity 
of  the  bacilli  in  the  case  of  men  is  not 
parallel  to  their  virulence  in  animals. 
The  course  of  epidemics  cannot  be  at- 
tributed alone  to  the  biological  charac- 
teristics of  comma  bacilli.  It  is  very 
probable  that  the  symbiosis  of  the  comma 
bacilli  with  other  species  of  micro-organ- 
isms found  in  the  dejections  and  in  the 
intestines  of  cholera  patients  plays  an 
important  role.  Blachstein  (St.  Peters- 
burger  med.  Woch.,  Jan.  27,  '94). 

Study  of  293  cases  of  cholera  in 
Arabia ;  the  comma  bacilli  found  in  2S0. 
Also  discovered  bacilli  in  his  own  stools 
without  having  any  of  the  symptoms  of 
cholera.  Immunity  is  possibly  the  result 
of  an  attack  of  cholera  experienced  in 
1892.  Karlinski  (Centralb.  f.  Bakt.  u. 
Parisitenk.,  May  19,  '94). 

Very  severe  and  even  rapidly  fatal 
cases  of  cholera  occur  with  all  the  char- 
acteristic sj'mptoms  of  the  disease,  yet 
careful  examination  fails  to  show  bacilli 
in  the  stools;  and  that,  on  the  other 
hand,  cases  which  are  clinically  identical 
with  mild  diarrhoea  may  yet  have  abun- 
dant bacilli  in  the  discharges.  Kadecki 
(St.  Petersburger  med.  Woch.,  Feb.  17, 
'94). 

It  is  not  sufficient  in  explaining  ty- 
phoid and  cholera  epidemics  to  demon- 
strate tlie  presence  of  the  typhoid  and 
cholera  bacilli  in  the  water  (X),but  that 
there  is  another  factor:   a  local  one  con- 
nected with  the  soil   (Pettonkofer's  Y). 
Von      Pettenkofer      (Mllnchencr      med. 
Woch.,  May  2,  '99). 
Of    course,    a    polluted    water-supply 
may  aggravate  an  epidemic  of  cholera  by 
furnisliing  a  good  medium  of  culture, 
and  a  good  water-supply  may,  on  the 
contrary,  lessen  an  epidemic;    but  the 
spread  of  the  disea-se,  by  means  of  drink- 
ing-water, is  not  satisfactorily  explicable. 
.State  of  our  knowledge  regarding  the 
cauHation   of  cholera,  as  Hhown  by  the 


epidemic  of  1S92-93.  The  history  of  this 
epidemic  shows  that  the  disease  does  not 
spread  by  means  of  contaminated  rivers, 
since  it  extended  from  large  cities  rap- 
idly toward  the  interior,  in  the  direction 
opposite  to  the  course  of  the  stream. 
Neither  did  the  contamination  of  drink- 
ing-water satisfactorily  account  for  its 
spread.  The  dejecta  contain  cholera  ba- 
cilli and  the  cholera  contagium, — viz.: 
the  spores  which  are  produced  by  the 
bacilli, — the  latter  being  more  tenacious 
of  life  than  the  bacilli,  and  also  more 
virulent.  The  disease  is  spread  by  arti- 
cles soiled  by  dejecta  or  by  the  diffusion 
of  the  dried  pulverized  dejecta  through 
the  air.  Consequently  cholera  epidemics 
are  most  apt  to  arise  in  dry  seasons.  The 
contagium  of  cholera  always  enters  the 
system  'through  the  digestive  apparatus. 
These  deductions  teach  us  the  great  im- 
portance, from  the  stand-point  of  pre- 
vention, of  bringing  all  dejecta  and  ob- 
jects soiled  by  them  under  water  as  soon 
as  possible.  Lachmann  (Deutsche  med. 
Zeit.,  Jan.  4,  '94). 

Vibrios  are  present  in  sewage  and 
Seine  water,  Paris,  and  in  Verseilles 
drinking-water,  when  no  cholera  is  pres- 
ent. Sanarelli  (Ann.  do  I'lnst.  Pasteur, 
vol.  vii,  p.  G93,  '95). 

Same  observations  in  the  Spree,  Oder, 
and  Havel  streams  and  Berlin  water- 
supply.  In  the  latter  two  the  vibrio  was 
found  pathogenic  and  gave  cholera-red 
reaction.  The  Massowah  vibrio  and 
phosphorescent  vibrios  from  Hamburg 
are  probably  the  true  cholera  vibrios. 
Pfeiffer  (Zeit.  f.  Hygiene  u.  Infcctionskr., 
B.  1,  p.  759,  '95). 

There  are  1.50  varieties  of  vibrios  differ- 
ing greatly  from  Koch's,  but  growing 
typical  specimens  for  some  time  in  water. 
Dunbar  (Deut.  med.  Woch.,  p.  138,  '95). 

Evidence  showing  direct,  positive 
agency  of  polluted  water  in  the  causa- 
tion and  spread  of  Asiatic  cholera. 
Oetvijs  (Le  Bull.  M(Jd.,  Jan.  9,  '95)  ; 
Fallot,  Cassoute,  and  Bouissou  (Mar- 
seille-mCd.,  Oct.  1,  '94);  KOrber  (Zeit 
f.  Hygiene  u.  Infcctionskr.,  p.  101,  '95) ; 
von  Heusingor  and  C.  Fiilnkel  (Berliner 
klin.  Woch.,  Mar.  25,  '95)  ;  Clemow 
(IJrit.  Med.  Jour.,  Oct.  13,  '94). 

Experiments  showing  that  vibrios  may 


CHOLERA  ASIATICA.     ORIGIN  AND  TRANSinSSION. 


137 


survive  an  entire  winter  and  freezing. 
Kasansky  (Centralb.  f.  Bakt.  u.  Para- 
sitenk.,  p.  184,  '95). 

Vibrios  in  fseeal  matter,  as  a  rule,  die 
within  the  first  20  days,  seldom  living  30. 
Vibrios  are  sometimes  present  without 
diarrhoea  or  other  choleraic  symptoms, 
even  in  formed  stools.  Rumpel  (Berliner 
klin.  Woch.,  No.  4,  '95) ;  Abel  and 
Clausen  (Centralb.  f.  Bact.  u.  Parasitenk., 
B.  17,  p.  77,  '95). 

The  water  of  a  town  containing  sew- 
age in  which  faecal  material,  urine,  etc., 
is  present  rapidly  destroys  the  vitality  of 
cholera  vibrios,  and  the  danger  of  a 
spreading  of  cholera  by  canal-water  or 
sewage  in  which  no  ftecal  material  or 
only  a  very  small  quantity  is  present  is 
much  greater.  Stutzer  (Centr.  f.  Bakt., 
Parasitenk.,  etc.,  p.  200,  '98). 

Correspondence  between  cholera  and 
the  prevalence  of  comma  bacteria  in 
well-water  of  Gujerat  during  the  famine 
of  1900.  The  results  of  researches  show 
that  none  of  the  comma-shaped  bacteria 
isolated  from  Gujerat  waters  could  be 
termed  true  cholera  vibrio.  There  was, 
liowever,  a  marked  resemblance  mor- 
phologically, biologically,  and  tinctori- 
ally  with  the  true  cholera-producing 
microbe.  So  marked  was  this  similarity 
that  it  is  personally  believed  that  the 
bacteria  found  belonged  to  the  tribe  of 
curved  bacteria,  which  includes  the  true 
cholera-producing  microbes.  In  many 
of  the  localities  where  these  comma 
bacteria  were  found  cases  of  true 
cholera  were  present,  which  shows  an 
enhanced  significance  between  the  inci- 
dence of  cholera  in  a  locality  and  the 
presence  of  curved  comma-sha])e(l  micro- 
organisms. G.  Lamb  (Pliila.  Med.  Jour., 
from  Lancet,  Apr.  20,  1901). 

But,  though  Pettenkofer's  theory  is 
based  upon  serious  arguments,  on  the 
other  hand,  it  is  not  less  demonstrated, 
according  to  the  views  of  Koch,  that 
cholera,  in  a  large  proportion  of  cases, 
is  transmitted  through  drinking-water 
and  several  kinds  of  food,  as  milk,  fresh 
vegetables,  fruits,  etc.,  soiled  by  the  de- 
jecta, showing  in  the  clearest  manner 
possible,  that  germs,  coming  from  stools 


of  choleraic  patients,  are  swallowed  and 
find  their  way  to  the  stomach  and  to  the 
intestine,  whose  alkaline  juice  is  neces- 
sary for  their  growth,  and  in  which  the 
entire  process  of  cholera  runs  its  course. 
Vibrios   are   destroyed   in   fresh   milk 
within  twelve  hours.     Hesse    (Deutsche 
Viertel.  f.  offentliche  Gesund.,  B.  20,  p. 
G52,  '95). 

Experiments     showing    that     cholera 
vibrios  live  at  least  thirty-eight  hours 
in  milk,  and  that  they  develop  until  the 
milk  coagulates  at  ordinary  temperature. 
They  may  even  live  in  coagulated  milk. 
Basenau    (Archiv  f.   Hyg.,  B.   23,   H.   2, 
'95). 
The  infection,  however,  may  be  still 
inhaled,  coughed  up,  and  afterward  swal- 
lowed;  so  that  a  diffusion  of  the  dried, 
pulverized  stools  through  the  air  cannot 
be  excluded.    But  in  every  case  the  con- 
tagion   of    cholera    enters    the    system 
through  the  digestive  apparatus. 

Indeed,  we  are  of  the  opinion  that 
both  theories  are  in  accordance  with 
fact,  and  that,  while  direct  infection 
through  drinking-water  and  food  is  an 
important  factor  in  the  propagation  of 
the  disease,  on  the  other  hand,  the  de- 
velopment of  epidemics  and  the  prefer- 
ence shown  by  cholera  for  certain  places 
can  only  be  explained  by  certain  unsani- 
tary conditions  and  a  peculiar  constitu- 
tion of  their  soil,  especially  favorable  to 
the  life  and  gro\s-th  of  the  cholera  germs. 
Asiatic  cholera  must  be  regarded,  there- 
fore, as  a  contagious  and  miasmatic 
disease. 

E.\pcriments  with  files  showing  that 
they  are  most  successful  infection-car- 
riers. A  fly,  which  had  been  infected 
by  being  put  vipon  a  mass  of  cholera  ba- 
cilli, was  placed  on  a  piece  of  beef,  which, 
after  a  time,  was  found  to  contain  an 
enormous  number  of  living  bacteria. 
riTelmnn    (Lancet.  .July   15.   '93). 

Scries  of  experiments  showing  that  not 
only  the  comma  bacillus,  but  also  other 
bacteria  existing  in  the  intestines  of  chol- 
eraic cadavers,  arc  preserved  in  the  in- 


138 


CHOLERA  ASIATIOA.     ORIGIN  AND  TRANSMISSION. 


testines  of  flies  at  least  three  davs;  bac- 
terium thought  to  be  the  vibrio  Metsch- 
nikowi,  when  removed  from  the  intes- 
tines of  flies  three  days  after  infection, 
killed  a  guinea-pig  and  a  pigeon  after 
the  same  lapse  of  time  (twenty-four 
hours)  as  a  vibrio  received  directly  from 
the  intestines  of  a  choleraic  cadaver. 
Savtschenko  (Wratsch,  No.  45,  '93). 

The  danger  of  infection  by  the  postal 
service  is  exceedingly  great.  A  letter 
infected  with  cholera  bacilli  put,  as  in 
the  ordinary  way,  into  a  post-bag  was 
found,  after  twenty-three  hours  and  a 
half,  to  be  still  covered  with  living  bacilli. 
On  post-cards  they  were  found  living 
twenty  hours  after  infection.  On  coins 
the  bacilli  died  with  remarkable  rapid- 
ity, whereas,  on  woolen  and  linen  stuffs 
they  enjoyed  a  particularly  long  life. 
Uffelman   (Lancet,  July  15,  '93). 

It  is  possible  for  the  cholera  spirillum 
to  be  taken  up  in  the  air  in  dust,  and 
thus  transported.  Uffelman  (Berliner 
klin.  Woch.,  June  26,  '93). 

Account  of  an  outbreak  of  cholera  in 
Burdwan  jail,  furnishing  strong  presump- 
tive evidence  in  favor  of  the  theory  that 
flies  may  spread  disease.     Nine  cases  of 
cholera,  4  of  which  were  fatal,  occurred 
in  G  different  sleeping  wards.    Just  out- 
side of  the  jail-walls,  at  the  corner  where 
the  ordinary  prisoners  were  fed,  were  a 
deserted  compound  and  row  of  dirty  huts, 
where  a  year  ago  had  been  a  number  of 
fatal  cases  of  cholera.     Swarms  of  flies 
were  blown  by  this  wind  from  the  huts 
into  the  jail-yard,  wliere,  on  reaching  the 
trees  and  corner  of  the   high  jail-wall, 
they   obtained   shelter  from   the   storm 
and  settled  on  the  food  exposed  on  plates 
before  the  gang  which  fed  at  this  corner. 
All   the  affected   prisoners  were   fed   at 
this  place  on  the  evening  of  the  storm. 
Surgeon   Captain   W.  J.  Buchanan    (In- 
dian Med.  Oaz.,  Mar.,  '97). 
But,  whatever  its  origin  may  be,  the 
disease  does  not  attack  all  those  who  are 
exposed  to  it;    in  fact,  during  an  epi- 
demic we  see  that  it  develops  mainly  in 
those    who    are   predisposed    to    it,    on 
account  of  previous  diseases,  dietetic  er- 
rors, mental  or  physical  strains,  and  other 
causes  disturbing  digestion  or  generally 


diminishing    the    organic    resistance    of 

the  individual. 

The  healthy  human  body  does  not 
furnish  a  congenial  ground  for  the  spe- 
cific bacillus.  Out  of  39  persons,  mostly 
of  the  pauper  class,  who  died  of  cholera, 
and  were  examined  at  the  Hospital  of 
St.  Peter  and  St.  Paul  in  1S92,  the  fol- 
lowing results  were  found  as  to  the 
presence  of  other  diseases: — 

Cases.       Per  cent. 
Nephritis  chronica  in- 

terstitialis   35  90 

Dilatatio   ventriculi.  .  28  70 

Sclerosis  eranii IS  45 

Cirrhosis  hepatis 16  40 

Gastritis  glandularis.  15  37 

Pleuritis  adhesiva....  8  20 
Atheroma     aortoe     et 

arteriarum  cerebri.  7  17 
Endocarditis     vegeta- 

tiva   4  10 

Pachymeningitis    ....  3                  7.5 

In  21  women,  in  whom  autopsies  were 
made,  abortion  was  found  to  have  oc- 
curred 7  times.  Eewowski  (Archives  des 
Sci.  Biol.,  p.  517,  '92). 

Alcohol  increases  six  times  the  degree 
of  predisposition,  in  a  given  individual, 
to  choleraic  infection,  not  only  by  modi- 
fying cellular  function  and  causing  vas- 
cular troubles,  but  also  by  decreasing 
the  bactericidal  power  of  the  blood. 
Thomas  (Arcliiv  f.  exper.  Path.  u. 
Pharm.,  Aug.  24,  '93). 

In  eases  of  alcoholics  mild  cholera,  like 
trautmatism,  is  capable  of  producing  de- 
lirium tremens,  and  may  also  account 
for  a  sudden  aggravation  of  light  cases. 
L.  Galliard  (Archives  GCn.  de  MCd.,  Oct., 
'93). 

Natural  immunity  against  cholera 
which,  according  to  Koch,  exists  in  half 
of  the  human  race.  The  exact  way  in 
which  this  acts  is  not  yet  clear,  but  it 
is  probable  that  the  toxin  generated  in 
the  intestinal  canal  by  the  vibrios  of 
cholera  becomes  changed  by  the  nuclein, 
during  absorption,  into  an  immunizing 
substance,  or  antitoxin.  It  is  a  pecul- 
iarity of  the  living  cell  to  be  able  to 
preserve  a  free  acid  in  an  alkaline 
medium.  When  tlie  life  of  tlie  cell  is 
destroyed  the  barrier  is  removed  to  the 


CHOLERA  ASIATICA.    SYMPTOMS. 


139 


entrance  of  tlie  cholera  bacilli.     Klem- 
perer  (Deutsche  med.Woch.,  May  17,  '94). 
Some    persons    exposed    to    action    of 
vibrios  remain  unafTected.    Immunity  is 
not  due  to  killing  of  all  microbes  in  the 
stomach.    Abel  and  Clausen  (Centralb.  f. 
Bact.  u.  Parasitenk.,  B.  17,  p.  77,  '95). 
We  see  that  under  certain  meteorolog- 
ical clianges  the  epidemics  show  often 
quite  marked  exacerbations,  and  that, 
when  the  private  and  public  sanitary 
conditions  correspond   to   scientific  re- 
quirements, the   disease   is  always  less 
grave  and  more  localized  than  under  con- 
trary circumstances. 

The  marked  influence  of  winda  and 
moisture  is  undeniable.  RosanofT  (La 
Tribune  M6d.,  Jan.  2,  '95). 

Prevalence  and  mortality  of  Madras 
Presidency  associated  with  two  mon- 
soons caused  by  rains,  induced  rise  of 
subsoil-water  and  development  of  condi- 
tions suitable  for  seasonable  epidemic. 
W.  G.  King  (Brit.  Med.  Jour.,  Feb.  2, 
'95). 

Pettenkofer's  view   of   the   important 
part  played  by  the  level  of  the  ground- 
water in   the  cholera  epidemic   in   1892 
supported  by  comparative  charts  show- 
ing the  amount  of  rain-fall,  the  number 
of  cholera  cases,  and  the  level  of  the 
ground  -  water.     As   the  ground  -  water 
sank,  cholera  increased.    P.  Hauser  (La 
MCd.  Mod.,  June  9,  13,  '94). 
Symptoms.  —  The    duration    of    the 
period  of  incubation  ranges  in  the  ma- 
jority of  cases  from  36  to  56  hours;   it 
very  rarely  extends  over  several  days. 

The  clinical  course  of  cholera  may  be 
divided  into  three  periods:  (1)  'premoni- 
tory diarrhwa;  (2)  confirmed  cholera;  (3) 
reaction. 

Prenionilori/  diarrhoea  begins  more 
frequently  at  night,  with  or  without 
colicky  pains,  under  the  form  of  liquid 
stools,  at  first  faecaloid  and  then  bilious 
and  serous,  with  borborigmus,  but  with- 
out tenesmus.  Generally  there  is  no 
fever,  and  no  trouble  of  the  appetite  and 
of  the  general  well-being;    so  that  pa- 


tients may  not  be  obliged  to  go  to  bed. 
But,  after  it  has  lasted  for  a  more  or  less 
long  time  (from  a  few  hours  to  several 
days),  the  patient  begins  to  feel  a  sense 
of  weakness,  pains  in  the  limbs,  dizzi- 
ness, shiverings,  and  mental  torpor.  Pre- 
monitory diarrhoea  is  always  of  choleraic 
nature,  as  the  stools  contain  the  specific 
germs  and  may  disseminate  the  infection. 
It  is  not  constant,  being  found  only  in 
one-third  or  two-thirds  of  the  cases  (ac- 
cording to  the  different  statistics);  but 
it  may  be  the  sole  manifestation  of  a  very 
slight  cholera. 

Confirmed  cholera  is  announced  by  a 
change  in  the  aspect  of  the  stools,  which, 
while  becoming  more  frequent,  consist 
of  an  aqueous  fluid,  without  any  fcecaloid 
smell  or  appearance,  in  which  many 
whitish,  mucous  flakes  float,  resembling 
grains  of  rice  (whence  their  name  of 
"rice-water"  or  "riziform"  stools), 
formed  by  the  epithelial  detritus  and 
containing  the  cholera  vibrios.  In  the 
meantime  vomiting  sets  in,  also  of  an 
aqueous  material  and  accompanied  by 
cramps  in  the  stomach  and  pra;cordial 
uneasiness.  The  thirst  becomes  burning 
and  insatiable.  The  urine  is  scanty, 
often  showing  albumin  and  sugar  (which 
disappear  when  recovery  begins);  but  in 
many  cases  these  are  totally  wanting,  a 
complete  anuria  being  the  rule  in  grave 
forms.  The  tongue  is  whitish,  large, 
and  damp.  Palpation  of  the  abdomen 
shows  the  anterior  wall  depressed  and 
somewhat  hardened.  In  proportion  to 
the  increase  of  the  diarrha?a  and  vomit- 
ing the  patient  grows  weaker  and  weaker; 
the  extremities  become  cold;  the  pulse 
small,  weak,  and  accelerated;  painful 
cramps  develop  in  the  calves;  sinking  of 
the  features  with  sharpened,  cold  nose, 
sets  in;  and  the  circulation  becomes 
sluggish,  constituting  together  the  "algid 
stage." 


140 


CHOLERA  ASIATICA.    SYMPTOMS. 


This  period  may  last  from  a  few  hours 
to  one  or  two  days,  and  may  end  in 
recovery  with  a  progressive  amendment 
of  all  the  symptoms,  constituting  then 
the  form  to  which  the  name  "cholerine" 
was  given  by  some  authors;  or  it  may 
end  in  death  with  symptoms  of  profound 
exhaustion,  or  finally  pass,  as  we  have 
said,  into  the  algid  stage. 

This  is  announced  by  a  lessened  fre- 
quency and  abundance  of  the  dejections, 
which  sometimes  cease  altogether.  In 
a  few  hours,  however,  the  patient's 
general  condition  grows  rapidly  worse; 
the  countenance  is  altered, — the  cheeks 
become  hollow,  the  eyes  sunk  deeper  in 
the  sockets,  are  encircled  by  a  black  ring; 
there  are  pains  in  the  head,  ear-tinglings, 
dizziness,  and  blurred  vision;  the  voice 
becomes  hoarse  and  is  soon  extinguished. 
A  feeling  of  anxiety  assails  the  patient, 
who  suffers  from  the  most  excruciating 
vomiting,  hiccough,  and  cramps  in  the 
calves.  Cooling  of  the  surface  increases, 
all  external  parts  being,  as  it  were, 
frozen;  but  the  patient  feels  an  internal, 
very  troublesome  heat,  explained  by  the 
fact  that  the  temperature  of  the  skin, 
mouth,  etc.,  is  much  lowered,  while  that 
of  internal  organs  is  raised  and  even 
febrile.  At  the  same  time  the  skin  takes 
a  bluish  tinge,  with  black  marble-like 
veins  coursing  over  the  hands,  feet, 
penis,  and  with  increasing  cyanotic  dark 
hue  of  the  nails.  The  pulse  becomes 
weaker  and  smaller,  until  it  disappears, 
first  from  the  radial  arteries  and  then 
from  the  crurals  and  even  the  carotids, 
while  the  heart-beats  gradually  disap- 
pear, the  sounds  becoming  weaker  until 
finally  only  the  second  sound  is  heard. 
To  this  great  emaciation  is  added,  the 
body  growing  thin  and  the  skin  wrin- 
kled. Breathing  is  frequent  and  diffi- 
cult; every  secretion  is  dried  up,  with 
the  exception  of  that  of  the  sudoriferous 


glands,  a  cold  and  clammy  sweat  cover- 
ing the  cutaneous  surface.  At  the  end 
of  this  stage  the  patient  becomes  ex- 
tremely apathetic  and  somnolent,  loses 
consciousness,  slowly  turning  his  eyes 
toward  a  person  speaking  to  him,  and  at 
times  answering  some  words  with  great 
fatigue,  but  immediately  falling  again 
into  stupor.  A  period  of  agitation,  dur- 
ing which  the  patient  tries  to  rise  and 
utter  vague  words  sometimes  precedes 
this  stage  of  collapse,  which  generally — 
in  more  than  three-fourths  of  all  the 
cases — grows  worse,  and  ends  in  death. 
The  whole  duration  of  the  algid  stage  is 
from  a  few  hours  to  two  or  three  days. 

Signs  of  death  in  clioleraic  patients. 
The  cessations  of  respiratory  and  cardiac 
movements  are  not  certain  signs  of  death 
in  this  disease.  The  author  proposes  the 
following:  1.  With  an  oesophageal 
sound,  introduce  by  the  mouth  an  abun- 
dant quantity  of  water  into  the  digestive 
tube.  The  epithelial  dibiis  which  covers 
the  mucosa  will  become  softened  and  the 
water  be  absorbed.  2.  Place  the  body 
in  a  bath,  at  a  surrounding  temperature, 
the  head  naturally  above  water.  3.  In 
a  patient  considered  dead  from  cholera, 
make  a  small  incision  in  the  abdominal 
wall  and  inject  an  abundant  quantity  of 
warm  water  into  the  peritoneal  cavity, — 
an  operation  which,  in  the  event  of  re- 
vival, would  be  inoffensive.  Netter  (Re- 
vue M6d.  de  I'Est,  Aug.  18,  '92). 

Reaction. — When  death  does  not  take 
place  during  the  algid  stage,  symptoms 
of  improvement  may  show  themselves: 
the  cyanosis  disappears,  the  skin  gains 
some  warmth,  the  urine  begins  to  flow 
again  and  is  deep  colored,  charged  with 
urea  and  chlorides  and  very  often  albu- 
minous; at  the  same  time  the  pulse  re- 
sumes its  strength,  while  its  frequency 
decreases;  the  voice  returns,  breathing 
becomes  regular,  painful  cramps  disap- 
pear, little  by  little  the  different  func- 
tions are  re-established,  and  after  some 


CHOLERA  ASIATICA.     SYMPTOMS. 


141 


days  the  patient  enters  into  a  state  of 
complete  convalescence. 

But  the  reaction  does  not  always  take 
such  a  favorable  course.  Many  of  the 
choleraic  symptoms  (anuria,  cooling  of 
the  skin,  difficult  breathing,  etc.)  persist 
or  reappear,  and  digestive  troubles,  head- 
ache, nervous  disorders,  fever,  and  gen- 
eral depression  follow,  ending  in  a  form 
very  like  typhoid  fever;  whence  its  name 
of  cholera-iijplwid.  Such  cases  may  run 
toward  a  lethal  termination,  delirium  or 
coma  and  adynamic  symptoms  superven- 
ing; but  they  may  also  end  in  recovery. 
In  other  cases  the  reaction  may  be  very 
sluggish,  each  function  requiring  a  long 
time  to  become  regular,  and  a  remark- 
able degree  of  weakness,  somnolence, 
with  scanty,  albuminous  urine,  persist 
until  convalescence  sets  in. 

But  how  are  the  symptoms  of  cholera 
to  be  explained?  Several  theories  have 
been  proposed  to  solve  the  question;  but 
it  cannot  be  said  to  be  definitely  settled. 
It  seems,  however,  that  no  better  ex- 
planation can  be  given  than  that  of  the 
effects  of  the  cholera  vibrios  after  their 
penetration  into  the  intestine;  that  is, 
a  direct  injury  to  the  mucous  membrane 
of  the  gut  and  the  elaboration  there  of 
one  or  more  poisonous  substances  ("chol- 
eraic toxins'"),  which  enter  the  circula- 
tion. 

The  direct  injury,  under  the  form 
of  a  s]iecific  enteritis,  gives  rise  to  de- 
hydration of  the  organism,  for  the  great 
loss  of  water  through  vomiting  and  diar- 
rhoea, which  not  only  deprives  the  blood 
of  its  water,  but  indirectly  subtracts 
from  the  tissues  their  water-component. 
As  a  result,  the  blood  can  no  longer  get 
rid  of  the  regressive  products  physio- 
logically eliminated  by  it,  nor  perform 
the  function  of  liajmatosis,  while  tlie 
anatomical  elements  are  affected  in  their 
metabolism.     On  the   other  hand,  the 


toxins,  acting  on  the  nervous  system, 
mainly  through  a  lesion  of  the  sympa- 
thetic system  of  the  abdomen,  exert  a 
general  depressing  influence. 

The  cholera  vibrio  is  considerably  mod- 
ified by  micro-organisms  which  may  sur- 
round it.  The  immunity  and  suscepti- 
bility depend  upon  other  microbes  in  the 
intestinal  tract.  Koch's  bacillus  never- 
theless remains  the  specific  cause  of 
cholera.  Metschnikoff  (Ann.  de  I'Inst. 
Pasteur,  Paris,  p.  529,  '94)  ;  Fawitzky 
(Wratsch,  Nos.  47,  51,  '94)  ;  Rontaler 
(Miinchener  med.  Woch.,  May  21,  '95). 

There  is  no  antagonism  between  the 
cholera  vibrio  and  the  comma  bacillus. 
Kempner  (Centralb.  f.  Bakt.  u.  Para- 
sitenk.,  B.  17,  H.  1,  '95). 

Several  complications  may  be  observed 
during  the  period  of  reaction,  among 
which  the  following  are  more  common: 
Cutaneous  eruptions  (papulous  ery- 
thema, urticaria,  miliaria,  zona,  roseola, 
petechia2,  vibices,  boils,  etc.),  oedema  of 
the  glottis,  diphtheritic  angina,  mumps, 
thrush,  dysenteric  enteritis,  bronchitis, 
pneumonia,  cerebral  congestion,  men- 
ingoencephalitis, hjemorrhage,  and  soft- 
ening of  the  brain,  which  may  give,  of 
course,  a  great  variety  of  clinical  aspects 
to  the  disease. 

Cholera  assumes  an  epidemic  form  of 
grave  dimensions  in  Canton  now  and 
then.  Small  outbreaks  have  occurred 
since  the  great  epidemic  of  1894.  Dur- 
ing this  year  that  country  sufTered  from 
prolonged  drought  and  intense  heat.  A 
comparison  of  the  clinical  course  of 
cholera  and  the  effects  of  the  treat- 
ment has  shown  that  the  onset  in  every 
case  was  sudden,  particularly  in  the 
earlier  cases  when  the  disease  was  most 
virulent,  vomiting  and  diarrhoea  being 
early  signs.  Delay  in  the  treatment  of 
this  stage  meant  certain  death,  and  the 
writer  states  that  he  has  not  seen  one 
patient  recover  when  treatment  was  de- 
layed,— that  is:  during  the  early  weeks 
of  the  epidemic,  while  toward  the  end 
of  the  epidemic  the  virulence  of  the  dis- 


142 


CHOLERA  ASIATICA.     DIAGNOSIS. 


ease  decreased,  and  spontaneous  recov- 
ery sometimes  took  place.     The  earlier 
the  onset  of  cramps,  the  worse  the  prog- 
nosis, and  experience  shows  that  the  pa- 
tient does  not  recover  when  cramps  are 
a  well-marked  condition.     W.  J.  Webb 
Anderson   (Lancet,  Sept.  27,  1902). 
Convalescence,  as  a  rule,  is  long  and 
often  complicated  with  dyspepsia,  diar- 
rhcea,  palsies  or  spastic  disorders  in  the 
limbs  (sometimes  in  form  of  tetany),  and 
mental  troubles.     Ansemia  is  present  in 
a  large  proportion  of  cases. 

An  attack  of  cholera  does  not  give  im- 
munity; so  that  even  after  recovery  has 
taken  place  a  new  infection  is  possible. 
The  clinical  forms  of  cholera  may  be 
very  different.  The  most  common  is 
that  described,  in  which  the  disease  runs 
through  its  typical  periods;  but  it  may 
limit  itself  to  the  first  stage,  being  a 
choleraic  diarrhoea  or  a  cholerine,  or  it 
may,  from  the  beginning,  show  the  grav- 
est symptoms  of  confirmed  cholera, 
rapidly  passing  into  the  algid  stage. 
Between  the  slight  and  the  grave  form 
there  are  all  the  possible  intermediate 
varieties. 

But  there  are  two  other  forms  worthy 
of  mention:  the  "foudroyant"  and  the 
"dry"  cholera.  The  true  cholera  foud- 
royant or  cholera  siderans  is  generally 
rare  and  mostly  observed  in  India;  the 
disease  then  kills  in  a  few  hours  or  even 
minutes;  or — as  observed  in  European 
epidemics — death  ensues  after  12  to  24 
hours.  The  name  of  "dry"  cholera  is 
given  to  those  cases  in  which  there  are 
no  diarrhceic  stools;  intestinal  exudation 
really  takes  place,  but,  probably  on  ac- 
count of  intestinal  paralysis,  the  fluid 
materials  arc  not  thrown  out.  These 
cases  are  often  rapidly  fatal. 

Diagnosis. — In  grave  cases  of  cholera 
the  diagnosis  is  not  difficult,  especially 
when  an  epidemic  of  the  disease  exists. 
Sometimes,  however,  the  clinical  appear- 


ance of  the  disease  may  be  very  like  that 
of  malarial  choleriform  pernicious  fever 
and  of  various  kinds  of  chemical  poison- 
ing. The  confusion  between  cholera  and 
malaria  may  arise  especially  in  countries 
where  both  infections  are  endemic,  such 
as  in  India.  Then,  besides  the  bacterio- 
logical examination  showing  the  specific 
germ  in  each  of  them,  the  effects  of 
quinine  may  indicate  an  important  dif- 
ference in  the  character,  malarial  fever 
ordinarily  yielding  to  its  action,  while 
cholera  generally  runs  its  course  despite 
the  largest  doses.  It  may  happen,  how- 
ever, that  both  diseases  attack  a  person 
at  the  same  time,  and  then  symptoms  of 
each  are  observed,  giving  rise  to  a  mixed 
form,  while  necropsy  shows  the  lesions 
of  either  infection  distinctly  developed. 
Poisoning  by  tartar  emetic  or  arsenic, 
the  symptoms  of  which  resemble  very 
much  those  of  the  choleraic  algid  stage, 
is  recognized  by  the  lesions  of  the  mouth 
and  lips,  by  the  vomiting  being  painful, 
burning,  and  preceding  diarrhoea,  and, 
in  doubtful  cases,  by  chemical  analysis 
of  vomited  matters. 

But  a  much  more  important  diagnostic 
question,  arising  especially  at  the  begin- 
ning of  an  epidemic  or  wlien  an  invasion 
of  cholera  is  to  be  feared,  relates  to  slight 
or  suspected  cases,  which  are  marked 
only  by  a  simple  diarrhoea  possessing  no 
specific  character.  It  is  of  the  greatest 
importance  to  ascertain,  on  account  of 
prophylactic  measures  to  be  at  once 
adopted,  whether  they  are  or  not  of 
choleraic  nature.  Tlie  diagnosis  can 
only  be  made  by  means  of  bacteriological 
examination;  fortunately  this  is  quite 
easy,  because  the  cholera  vibrios  always 
show  themselves  in  tlie  first  diarrhreal 
stools,  and  because  in  many  cases  the 
simple  examination  of  a  cover-glass 
preparation  of  the  stools  may  be  siifTi- 
cient  to  make  a  very  probable  diagnosis. 


CHOLERA  ASIATICA.     BACTKKXOLOGY. 


143 


When  mixed  with  tlie  serum  of  im- 
munized guinea-pigs,  and  inoculated  into 
the  peritoneal  cavity  of  susceptible  ani- 
mals, virulent  cultures  of  the  spirilla  in 
large  dose  remain  innocuous;  on  subse- 
quent examination  of  the  peritoneal  con- 
tents the  bacteria  can  be  seen  to  have 
undergone  disintegration  to  a  greater  or 
less  extent,  dependent  upon  the  relative 
immunizing  strength  of  the  serum  of  the 
immunized  animal.  This  power  of  de- 
stroying the  cholera  spirilla  is  believed 
to  depend  upon  the  presence  in  the  serum 
of  certain  antagonistic  substances  which 
have  a  distinct  inhibiting  influence  upon 
the  vital  processes  of  the  bacteria. 

Investigations  show  that  no  other  spe- 
cies of  bacteria  is  afl'ected  in  the  same 
way  by  mixing  with  the  serum.  Hence 
the  following  test  proposed:  A  loopful 
of  the  culture  to  be  tested  is  mixed  with 
a  cubic  centimetre  of  bouillon,  to  which 
ten  times  the  amount  of  serum  necessary 
to  protect  a  guinea-pig  of  200  grammes 
weight  from  a  similar  dose  of  virulent 
cholera  spirilla  has  been  added,  and  the 
whole  is  at  once  inoculated  into  the 
peritoneal  cavity  of  a  young  guinea-pig 
of  from  200  to  300  grammes  weight.  In 
the  inoculation  care  should  be  taken  to 
avoid  injury  of  the  intestines,  and  the 
cultures  employed  should  be  recent  and 
shoiild  have  been  shown  to  consist  of 
well-formed  and  actively  moving  germs. 

As  control,  a  similar  quantity  of  the 
same  culture  is  mixed  witli  a  cubic  centi- 
metre of  bullion  as  before,  an  amount 
of  ordinary  guinea-pig  serum  equal  to 
the  amount  of  immunizing  serum  made 
use  of  in  the  original  test  is  added,  and 
the  whole  is  inoculated  into  another 
guinea-pig. 

In  twenty  minutes  some  of  the  peri- 
toneal contents  in  each  case  is  with- 
drawn b}'  means  of  glass  pipettes,  and  is 
examined.  If  the  bacteria  are  the  spe- 
cific perms  of  cholera  they  present  a 
very  different  appearance  in  the  two 
cases.  Those  obtained  from  the  control- 
animal  are  well  formed,  active,  and  seem 
to  have  multiplied.  Those  which  were 
exposed  to  the  action  of  the  immunizing 
scrum  arc  small,  misshapen,  immobile 
for  the  most  part,  and  apparently  dead. 

Unless  a  distinct  difTerence  is  observ- 


able between  the  bacteria  in  the  two  ex- 
periments the  micro-organism  under  ex- 
amination must  be  regarded  as  probably 
twt  tlie  cholera  vibrio,  since  the  change 
described  is  very  constant  in  the  case 
of  the  cholera  germ,  and  has  not  been 
observed  to  occur  with  any  other  under 
similar  conditions.  PfeifTer  (Zeit.  f.  Hy- 
giene u.  Infectionskr.,  vol.  xix,  p.  75, '95). 
Serum  diagnosis:  When  the  blood- 
serum  of  an  animal  gives  a  good  reaction 
in  the  fresh  state,  the  reaction  may  also 
be  obtained  by  moistening  a  drop  of  the 
dried  blood  with  water  and  mixing  it 
with  an  actively  motile  choleraic  cul- 
ture. Wyatt  Johnston  and  E.  W.  Ham- 
mond (N.  Y.  Med.  Jour.,  Nov.  28,  '9G). 

According  to  Blachstein,  chrysoidin 
produces  agglutination  in  cholera  cul- 
tures in  exactly  the  same  manner  as  the 
diseased  serum  of  immune  animals,  and 
does  not  produce  agglutination  in  any 
other  form  of  vibrio.  Personal  experi- 
ments showing  that  the  chrysoidin  reac- 
tion was  not  specific  for  cholera.  Several 
vibrios  are  affected,  and  among  them  is 
included  the  vibrio  of  Asiatic  cholera, 
and  it  is  not  the  most  sensitive.  Walter 
Englcs  (Centralb.  f.  Bakt.,  Parasit.,  u. 
Infectionskr.,  Jan.  20,  '97). 

In   11  cases  examined  the  agglutina- 
tion of  the  cultures  of  the  cholera  vibrio 
was  shown  10  times  by  the  serum;  twice 
on  the  first  day  of  the  disease,  4  times 
on  the  second  day,  3  times  on  the  third 
day,  and  once  on  the  fourth  day.     The 
reaction  was  particularly  distinct  in  2 
of  the  patients  from  whom  the  blood 
was  taken  on  the  third  day.     The  phe- 
nomenon of  agglutination  ascertained  by 
them   was   absolutely   typical.      Achard 
and   Bensaude    (Presse    Med.,    Sept.   26, 
'97). 
Bacteriology. — The  specific  germ   of 
cholera  Asiatica  is  now — thanks  to  the 
researches  of  Koch  and  of  many  other 
authors — perfectly  known.     It  is  found 
especially  in  the  mucous  flakes  of  the 
stools    (and    in    the    vomited    matter). 
Wlien  these  are  spread  upon  an  object- 
glass,  dried,  and  stained  with  one  drop 
of  methyl-blue,  it  appears  in  the  shape 
of  rods,  measuring  1.5  to  2.5  microns  in 


144 


CHOLEKA  ASIATICA.    BACTERIOLOGY. 


length,  and  0.5  to  0.6  micron  in  width, 
and  being  generally  curved,  whence  the 
name  of  "comma  bacilli"  or  "bacilli 
vixgula"  given  to  them.  Sometimes, 
when  two  of  them  are  joined  at  their 
extremities,  in  a  direction '  opposed  to 
their  concavity,  the  resulting  form  is 
that  of  an  italic  S,  and  when  several 
bacilli  are  joined  to  each  other,  their 
shape  becomes  that  of  a  spiral  (choleraic 
"spirilla").  Cholera  bacilli  are  very 
movable  and  endowed  with  oscillatoi7 
movements  resembling  those  of  sperma- 
tozoa, and  also  with  progressive  move- 
ments. They  are  easily  cultivated  in 
several  culture-media,  as  in  broth  and 
upon  agar-agar  at  the  temperature  of  the 
human  body,  upon  gelatin  plates,  which 
become  slowly  liquefied,  and  upon  pota- 
toes, meat,  eggs,  milk,  and  several  other 
kinds  of  food.  The  broth-cultures  pro- 
duce indol  and  nitric  acid  (indol-nitrous 
reaction)  and  give  rise  to  a  peculiar  re- 
action with  hydrochloric  acid,  assuming 
a  violet-pink  color,  whose  intensity 
rapidly  increases  during  half  an  hour. 
This  reaction,  to  which  the  name  of 
"cholera  red"  was  given,  is  a  valuable 
diagnostic  sign  of  cholera  vibrios. 

Cholera  vibrios  can  live  only  for  a 
short  time  in  fiEcal  matter,  seldom 
longer  than  two  or  three  days;  so  that 
the  advisability  of  immediate  examina- 
tion of  the  dejecta  is  evident.  They  live, 
on  the  contrary,  very  long  in  the  soil, 
especially  when  they  find  in  it  a  proper 
nutritious  material;  it  seems  rather  that 
their  virulence  is  then  heightened,  the 
elaboration  of  their  poison  becoming 
more  rapid  and  intense.  They  can  live, 
also,  on  the  outer  surface  of  fruits  and 
vegetables  (the  duration  of  their  life  be- 
ing then  from  one  to  six  days)  and  even 
on  the  cut-surface  of  these,  where  their 
life  may  last  for  a  time  ranging  from  one 
hour  (on  very  acid  fruits)  to  two  weeks. 


Cholera  vibrios  can  grow  freely  in  water, 
especially  when  it  is  stagnant  and  pol- 
luted with  organic  matter;  and  it  has 
been  shown  that  they  can  live  for  many 
days  even  in  bottled  water. 

The  bacilli  are  destroyed  if  they  are  in 
free  contact  with  the  air  while  exposed 
to  the  sunlight,  but  the  colonies  in  the 
interior  of  the  culture-media  are  aided 
in  their  growth,  the  sunlight  serving  as 
a  sort  of  incubator.    When  the  medium 
is  plentiful,  there  is  more  growth  than 
destruction.     Virulence  is  not  diminished 
in    those    bacteria    that    show    growth. 
Therefore  bacteria  in  the  deeper  portions 
of  water  are  not  affected  bj'  the  solar 
rays,  while  those  floating  on  the  surface 
maj'  be  destroyed ;  conclusion  drawn  that 
"too  much  reliance  slioukl  not  be  placed 
on  the  bactericidal  action  of  sunlight." 
F.   F.   Westbrook    (Jour,   of   Path,   and 
Ba«t.,  Jan.,  '96). 
As  for  the  action  of  high  or  low  tem- 
perature upon  them,  we  know  that  the 
best    temperature    for    their   growth    is 
between  30°   and  40°   C;    that  under 
160°  C.  their  growth  is  checked,  but  their 
vitality  is  preserved,  even  if  zero  or  below 
zero  is  reached;  they  have  been  found  to 
resist  a  temperature  of  — 31.8°  C.  (34° 
F.),  so  that  it-  may  be  supposed  that  the 
germs    may    survive    an    entire    severe 
winter.    On  the  contrary,  they  arc  killed 
after  some  days  by  a  temperature  of  50° 
C,  and  in  a  shorter  time  by  a  tempera- 
ture of  75°  C.     Direct  sunlight  dimin- 
ishes, but  does  not  destroy,  their  vitality 
and  virulence. 

A  distinct  degree  of  alkalinity  is  neces- 
sary for  their  best  growtli  (this  being  the 
reason  of  their  development  in  the  in- 
testine), while  nearly  neutral  media  are 
very  unsuitable,  and  acids  are  decidedly 
inimical  to  them;  hence  they  cannot 
live  in  the  stomach.  Sulphuric,  hydro- 
chloric, and  phosphoric  acids,  fresh 
lemon-juice  and  wine  and  beers  contain- 
ing a  somewhat  large  proportion  of  acids, 
are  all  able,  in  a  different  degree,  to  kill 


CHOLERA  ASXATICA.     PATHOLOGY. 


145 


them.  Among  the  chemical  substances 
having  a  marked  microbicidal  action 
upon  cholera  vibrios,  the  most  energetic 
are  corrosive  sublimate  (1  to  10,000), 
sulphate  of  copper  (1  to  25,000),  and 
quinine  (1  to  5000).  Mustard-oil  and 
volatile  essences  generally  display  a  sim- 
ilar action. 

Asiatic  cholera  is  a  nitrate  poisoning, 
the  result  of  the  growth  of  the  specific 
bacterium.  Emmerich  and  Tsuboi  (Mun- 
chener  mcd.  Woch.,  June  20,  '03) ;  Klem- 
perer  (Berliner  klin.  Woch.,  p.  74,  '93). 

If  the  theory  of  Emmerich  and  Tsuboi 
upon  cholera  as  the  result  of  nitrate 
poisoning  produced  by  the  bacilli  is  true, 
more  than  one  cause  must  act  to  produce 
cholera.  Not  only  are  the  bacilli  neces- 
sai-y,  but  the  nitrites  also,  upon  which 
they  are  to  act  to  produce  nitrates.  The 
presence  of  carbohydrates  is  a  further 
essential.  R.  J.  Beck  (Med.  Corres.  des 
wurttembergischen  Arzt.  Landesvereins, 
Dec.  18,  28,  '93). 

The  specific  nature  of  the  comma 
bacilli  is  proved  by  their  being  found  ex- 
clusively in  the  intestinal  contents  of 
choleraic  patients;  but  it  is  proved,  too, 
by  experimental  production  of  a  cholera- 
like  disease  in  animals  through  ingestion 
or  inoculation  of  their  cultures.  Indeed, 
Koch,  liaving  previously  alkalinized  the 
stomach-contents  of  guinea-pigs,  intro- 
duced 10  cubic  centimetres  of  broth- 
culture  of  comma  bacilli  and  immedi- 
ately aftenvard  injected  into  the  peri- 
toneum 1  cubic  centimetre  of  tincture 
of  opium,  and  succeeded  in  producing 
an  intestinal  lesion  with  a  flaky,  diar- 
rhocal  fluid:  a  pure  culture  of  comma 
bacilli.  Other  experimenters,  by  inoculat- 
ing such  a  culture  into  the  peritoneum, 
observed  in  guinea-pigs  and  rabbits  a 
very  grave  disease,  with  extreme  weak- 
ness, low  temperature,  and  death  in  col- 
lapse. Inoculations  of  choleraic  virus  in 
man,  however,  gave  no  result. 

Cholera  vibrios  vary  to  a  considerable 

2- 


extent  in  their  pathogenic  attributes 
and  chromogenic  properties,  not  only 
when  they  grow  saprophytically  outside 
the  body,  but  also  when  they  are  ob- 
tained directly  from  the  intestine  of  a 
choleraic  patient;  so  that  many  forms  of 
them  have  been  described  as  dillerent 
organisms,  while  they  are  only  peculiar 
varieties  of  the  same  germ.  Moreover, 
it  seems  highly  probable  that  their  sym- 
biosis with  certain  species  of  microbes 
found  in  the  dejections  and  in  the  in- 
testines of  cholera  patients  play  an  im- 
portant part  in  the  increase  of  their 
virulence,  while  some  other  intestinal 
microbes  may,  on  the  eontrarj',  retard 
their  gro^vth  and  lessen  their  virulence. 

Peptone  water  cultures  (eight  hours), 
followed  by  agar  cultures  for  eight 
hours,  agglutination  in  hanging  drop 
can  establish  the  certain  diagnosis  of 
cholera  in  sixteen  hours.  The  principal 
condition  is  the  use  of  a  serum  of  high 
valence,  permanent  and  reliable.  The 
result  of  this  experimental  work 
proves  also  the  absolute  specificity  of 
Kocli's  vibrio  as  the  cause  of  cholera. 
W.  Kolb,  E.  Gotschlich,  H.  Hetsch,  0. 
Lenty,  and  R.  Otto  (Deutsche  med. 
Wochen.,  July  23,  1903). 

A  new  medium  of  great  service  in  the 
diagnosis  of  cholera.  To  prepare  it  20 
grammes  of  agar,  10  grammes  of  Lie- 
big's  extract,  10  grammes  of  peptone, 
and  5  grammes  of  salt  are  boiled  in  a 
litre  of  water  for  half  an  hour.  The 
mixture  is  filtered  and  boiled  for  an- 
other half-hour;  15  giammes  of  lactose 
are  added  to  it,  and  it  is  boiled  again 
for  a  quarter  of  an  hour.  Sufllcient  of 
a  sterilized  aqueous  solution  of  carbon- 
ate of  soda  to  turn  litmus-paper  just 
blue  is  added,  and  then  130  c.  c.  of 
Kulwl-Tiemann  litmus  solution  and  10 
c.  c.  of  crystal  violet  solution  (0.1  per 
cent,  in  hot  distilled  water)  arc  added, 
and  the  mixture  is  distributed  in  Petri 
dishes,  8  c.  c.  to  a  dish.  Hirschbruch 
and  Schwcr  (Centralb.  f.  Bakter.,  No. 
6,  Sept.,  1903). 

Pathology. — The  cliaracteristic  lesions 


146 


CHOLERA  ASLATICA.    PROGNOSIS. 


of  cholera  are  found  in  the  small  intes- 
tine, whose  inner  surface  is  covered  by 
a  whitish,  creamy  lining,  extending  froin 
the  pylorus  to  the  ileo-cascal  valve.  Its 
contents  are  generally  made  up  of  the 
well-known  rice-water  material;  this  has 
a  neutral  or  slightly-alkaline  reaction, 
and  contains  only  1  to  2  per  cent,  of 
solid  matter  (chloride  of  sodium,  carbo- 
nate of  ammonium,  a  little  urea,  and 
traces  of  salts  of  potash);  it  is  devoid  of 
albumin,  coloring  substances,  and  biliary 
salts.  The  mucous  membrane,  after  the 
lining  has  been  removed,  shows  a  red 
coloration,  more  or  less  marked,  accord- 
ing to  the  period  of  the  disease,  and  a 
number  of  small,  round  prominences, 
made  by  swelled  folliculi:  "psorentery." 
In  a  later  stage  the  lesions  are  more  pro- 
nounced: the  intestinal  contents  are 
bloody,  the  folliculi  are  ulcerated,  and 
the  mucous  membrane  shows  a  more  or 
less  extended  gangrene.  The  large  in- 
testine is  also  extremely  hypersmic, 
studded  with  htemorrhagic  patches  and 
ulcerations,  and  is  filled  with  black, 
bloody,  foetid,  feecal  matter.  Deepening 
of  the  ulcerations  may  give  rise  to  per- 
foration, with  all  its  dire  sequels.  Mi- 
croscopical examination  shows  a  vari- 
able degree  of  swelling  and  clouding  of 
the  epithelium,  and  extensive  desquama- 
tion of  the  small  intestine.  The  ade- 
noid tissue  of  the  mucous  membrane  and 
of  the  villi  is  filled  with  embryonic  cells, 
and  this  cellular  infiltration  is  also  found 
in  the  follicles  and  in  Peyer's  patches. 
The  muscular  layer  is  unafTected;  the 
subserous  connective  tissue  is  infiltrated 
with  leucocytes,  while  the  epithelial  layer 
of  the  peritoneum  has  disappeared. 
Anatomically,  therefore,  the  intestinal 
lesion  may  be  regarded  as  an  acute  des- 
quamative enteritis. 

In     the     kidneys     the     pathological 
changes  are  those  of  a  more  or  less  severe 


glomerular  nephritis,  or,  according  to 
Leyden,  of  a  coagulation  necrosis  of  the 
epithelium  without  any  inflammatory 
action.  In  the  former  case  the  morbid 
changes  would  be  explained  by  the  elim- 
ination of  toxins  passing  from  the  intes- 
tine into  the  blood;  in  the  second  by 
alterations  in  the  circulation  due  to  the 
profuse  loss  of  water.  An  epithelial  des- 
quamation is  observed  on  the  mucous 
membrane  of  the  bladder,  ureters,  and 
the  pelvis  of  the  kidne3's.  The  spleen  is 
hard  and  rather  small;  the  liver  is  con- 
gested and  its  cells  have  undergone 
granular  degeneration. 

As  for  the  cerebral  changes,  both  in 
the  algid  stage  and  in  the  period  of  re- 
action, they  are  likewise  of  the  nature  of 
acute  degeneration  and  necrosis. 

Cerebral  changes  in  Asiatic  cholera  in 
algid  state,  as  well  as  in  reaction  period, 
of  the  nature  of  an  acute  degeneration 
and  necrosis,  and  not  of  a  perivascular 
inflammation.     Tschistowitsch    (St.   Pe- 
tersburg med.  Woch.,  Aug.  17,  '95). 
Prognosis, — Cholera  Asiatica  is  always 
a  serious  disease,  even  when  its  symp- 
toms do  not  apparently  show  a  specially 
grave  character.     Considering  its  insidi- 
ous tendency  and  the  probability,  never 
lacking,    of    lethal    accidents    in    every 
period  of  its  course,  the  slightest  forms 
of  diarrhoea  may  be  regarded,  during  an 
epidemic,  as  the  onset  of  a  fatal  affection. 
In  the  algid  stage,  of  course,  the  prog- 
nosis is  still  more  unfavorable,  and  such 
symptoms  as  anxiety,  agitation,  collapse, 
weakness;  quickness  and,  moreover,  dis- 
appearance of  the  radial  pulse;   anuria, 
coma,    delirium,    and    convulsions    are 
almost   without    exception    of   very    ill 
omen.     As  for  the  period  of  reaction, 
the  prognosis  becomes  bad  when  cerebral 
or  pulmonary  complications  occur,  or  if 
its  course  is  irregular. 

At  the  beginning  of  an  epidemic,  the 
average  mortality  from  cholera  is  50  to 


CHOLERA  ASIATICA.    PROPHYLAXIS. 


147 


60  rer  cent,  and  even  higher,  while  at 
the  end,  slight  forms  generally  prevail- 
ing, it  grows  progressively  less.  The 
largest  proportion  of  deaths  occurs  in 
children  and  old  people,  the  ill-nour- 
ished, enfeebled,  paupers,  drunkards, 
and  those  affected  with  debilitating 
diseases,  especially  dysentery,  cancer, 
consumption,  insanity,  etc. 

Whatever  may  be  the  gravity  of  the 
symptoms  during  the  algid  stage,  even 
if  there  be  intense  cyanosis,  if  the  normal 
or  contracted  pupils  remain  mobile, — 
that  is  to  say,  if  they  dilate  when  the 
eyelids  are  closed  and  return  to  their 
primitive  diameter  as  soon  as  the  lids 
are  opened, — a  favorable  prognosis  may 
be  given.  Coste  (Revue  de  MOd.,  No.  12, 
'90). 

The  prognosis  of  Asiatic  cholera  in 
young  children  is  exceedingly  bad.  Of 
4129  infants,  aged  1  year  and  under,  80 
per  cent,  died;  of  1701  children,  from  1 
to  5  years,  75  per  cent,  died;  of  1731 
children,  from  5  to  15  years,  45  per  cent. 
Hoppe  (Deutsche  med.  Woch.,  Nov.  9, 
•93). 

There  is  a  urinary  crisis  in  patients 
who  recover,  characterized  by  the  dis 
charge  of  abundant  urine  of  low  specific 
gravity,  rich  in  urates,  but  poor  in  chlo- 
rides. As  convalescence  becomes  more 
marked,  the  proportion  of  urea  dimin- 
ishes, that  of  the  chlorides  increases,  the 
specific  gravity  grows  greater,  and  the 
quantity  of  urine  returns  to  normal. 
Carriou   (La  Mod.  Mod.,  Dee.  30,  '93). 

Prophylaxis. — Prophylactic  measures 
are  of  the  utmost  importance.  The  im- 
portation and  propagation  of  cholera 
must  be  thwarted  and  healthy  persons 
must  be  protected  against  contagion. 
The  measures  necessary  may  be  summed 
up  as  follows:  A  careful  examination  of 
persons  coming  from  infected  places; 
isolation  of  those  found  ill  or  simply 
mspected  and  of  their  nurses;  thorough 
disinfection  of  clothes,  linen,  premises, 
dejections,  rooms,  drains,  etc.     For  in- 


dividual prevention  it  is  necessary  to 
drink  only  boiled  water,  to  avoid  every 
dietetic  error,  excess,  mental  or  bodily 
strain,  cold;  and,  while  no  radical  change 
ought  to  be  made  in  the  ordinary  ali- 
mentation, the  food  must  be  of  good 
quality  and  vegetable  products  should 
always  be  cooked. 

Haffkine's  prophylactic  method,  based 
on  the  inoculation  of  serum  of  immu- 
nized animals,  has  been  tried  with  satis- 
factory results  in  India;  but  the  dura- 
tion of  the  protection  afforded  by  the 
inoculation,  and  for  some  authors  the 
efficiency  of  the  protection  itself,  is  still 
a  matter  of  doubt. 

An  e.xperimental  inquiry  of  the  bear- 
ing on  immunity  of  intracellular  and 
metabolic  bacterial  poisons:  As  far  as 
the  cholera  spirillum  is  concerned,  (1) 
any  one  mode  of  immunization  will  pro- 
tect an  animal  against  an  infection  by 
any  other  form  of  inoculation  used;  (2) 
the  serum  of  an  animal  immunized  by 
any  one  method  also  protects  guinea- 
pigs  against  an  infection  by  any  other 
forms  of  inoculation;  (3)  the  distinction 
between  an  "intracellular"  and  a  "metab- 
olic" poison  in  their  relation  to  artificial 
immunity  must  not  be  made  too  narrow. 
Kanthack  and  Westbrook  (Brit.  Med. 
Jour.,  Sept.  9,  '93). 

The  milk  from  an  immunized  goat  has 
the  property  of  conferring  immunity  to 
cholera,  but  not  when  introduced  into 
the  system  by  way  of  the  stomach.  It 
confers  immunity  at  once,  but  is  of  no 
avail  if  given  shortly  after  the  injection 
of  the  cholera  germs.  Ketschcr  (Archiv 
f.  exper.  Path.  u.  Pharni.,  Nov.,  '93). 

Endeavor  to  reconcile  the  various  di- 
vergent views  which  have  resulted  from 
the  studies  of  different  observers:  There 
are  in  the  cholera  vibrios  distinctly-poi- 
sonous substances,  which  are  insoluble  in 
the  ordinary  culture-media,  but  which 
are  set  free  after  the  death  of  the  bacilli 
in  the  bodies  of  guinea-pigs  used  for  ex- 
periments, and  which  then  act  as  paral- 
yzants to  the  centres  governing  the  cir- 


148 


CHOLERA  ASIATICA.     PROPHYLAXIS. 


culation  and  the  temperature.  Conclu- 
sion that,  although  the  possibility  of  a 
successful  protective  inoculation  against 
human  cholera  cannot  be  denied,  the 
existence  of  such  a  possibility  has  not 
yet  been  proved  experimentally.  R. 
Pfeiffer  (Zeit.  f.  Hygiene  u.  Infectionskr., 
Mar.  2,  -94). 

Substances  found  in  blood  of  conva- 
lescents afiord  inconstant  immunity. 
Sobernheim   (Hyg.  Rund.,  p.  145,  '95). 

Haft'kine's  inoculations  in  India  in- 
creased safety  of  inoculated  twenty 
times.  W.  J.  Simpson  (Brit.  Med.  Jour., 
Sept.  21,  '95). 

Out  of  3276  uninoculated  persons  there 
■were  47  cases;  while  in  2936  inoculated, 
3  cases.  Powell  (Indian  Med.  Gaz.,  No. 
7,  '95). 

ICitasato's  anticholera  serum  used  in 
193  cases.  The  former  rate  of  mortality 
(among  Japanese)  has  been  about  70 
per  cent.  In  these  cases  the  percentage 
was  lowered  about  20.  The  subsidiary 
results  were  similar  to  those  of  diph- 
theria antitoxin:  1.  Urticaria,  veiy 
common.  2.  Arthralgia,  observed  in  only 
18  cases.  3.  Myalgia  in  6  cases.  A. 
Nakagawa  (Brit.  Med.  Jour.,  No.  1855, 
p.  121,  '96). 

Summary  of  all  the  observations  in 
India  upon  HafTkine's  anticholera  inocu- 
lations. 1.  The  inoculations  even  in 
the  larger  doses  hitherto  used  do  not 
confer  a  complete  immunity.  2.  A  con- 
siderable degree  of  immunity  seems  to 
be  conferred  when  the  doses  injected  are 
sufTiciently  large  to  produce  marked  fe- 
brile reaction.  3.  Smaller  doses  confer 
little  or  short-lived  protection.  Arthur 
Powell  (Lancet,  No.  3803,  p.  109,  '00). 

Complete  report  of  the  results  of  the 
anticholeraic  inoculations  performed  in 
Calcutta  during  two  years.  Among  054 
uninoculated  persons  there  were  71 
deatlis,  while  among  the  402  inoculated 
individuals  in  the  same  households  there 
were  12  deaths:  a  reduction  of  mortality 
of  72.47  per  cent.  The  results  in  Cal- 
cutta are  fully  confirmed  by  reports  from 
other  parts  of  India,  which  are  also 
given,  Simpson  (Indian  Mcd.-Chir.  Rev., 
July,  '90). 

Epidemic  in  1895  in  the  town  of  Midna- 
pore,  Bengal,  in  which  the  method  sug- 


gested by  Hankin  of  disinfecting  the 
wells  by  permanganate  of  potassium  was 
used.  It  undoubtedly  cut  short  the  epi- 
demic, statistics  showing  the  value  of  the 
method.  O'Gorman  (Indian  Med.  Gaz., 
July,  '96). 

Referring  to  the  researches  which  have 
shown  that  the  protective  action  of  the 
cholera  serum  is  strictly  specific,  and  is 
due  to  the  presence  of  specific  bacteri- 
cidal substances:  The  serum  of  persona 
inoculated  with  cholera  vibrios  contained 
these  substances,  and  not  bodies  anti- 
toxic to  the  cholera  poison  belonging 
to  the  vibrios  themselves.  The  value  of 
inoculations  emphasized  in  India,  al- 
though the  protection  lasts  only  a  year. 
Kolle  (Deutsche  med.  Woch.,  Jan.  1, '97). 

Detailed  statement  of  results  of  anti- 
cholera inoculation.  In  Gaya  jail,  of  433 
prisoners,  215  submitted  to  inoculation, 
after  cholera  had  appeared  in  the  prison. 
Among  the  inoculated  there  occurred  8 
cases,  with  3  deaths;  among  the  unpro- 
tected, 20  cases,  with  10  deaths.  Haff- 
kine  (Dublin  Jour,  of  Med.  Science,  Feb., 
'97). 

The  number  of  micro-organisms  in 
well-water  may  be  materially  reduced 
for  several  days  by  placing  potassium 
permanganate  in  the  well.  Attempt  to 
check  choleraic  outbreaks  in  India  by 
putting  the  permanganate  salt  in  the 
wells  of  villages  in  which  the  outbreaks 
occurred.  Enough  was  used  to  give  the 
water  a  pink  color  until  the  following 
day,  generally  two  or  three  ounces,  and 
the  procedure  was  repeated  every  third 
or  fourth  day.  As  a  result,  the  cholera 
outbreaks  were  of  shorter  duration,  and 
cases  fewer  in  these  villages  than  in 
those  using  water  from  wells  that  had 
not  been  so  treated.  E.  II.  Ilankin  (Brit. 
Med.  Jour.,  Jan.  22,  '98). 

A  cholera  vaccine  which  contains 
free  receptors,  and  which  has  the  power 
of  building  both  uni-  and  amboceptors 
(agglutinins  and  bacteriolysins)  in  a 
cholera  immune  serum  is  obtainable  by 
autolytic  digestion  of  cholera  spirilla 
in  aqueous  solution.  When  injected 
into  rabbits  this  vaccine  gives  rise  to 
the  Hiipearance  of  bactericidal  and  ag- 
glutinative substances  in  the  blood-sera 
(;f  these  animals  which  equal  or  exceed 


CHOLERA  ASIATICA.     TREATMENT. 


149 


those     obtained     from     inoculation     of 
virulent     living    cholera     vibrios.     One 
advantage   gained    by    the   use    of   the 
vaccine   instead   of   the   living   or   dead 
bacteria  is  the  absence  of  local  reaction 
following  the  inoculation.     The  vaccine 
filtrate   may  be  evaporated  to   a   pow- 
der,  which   when   redissolved   in   water 
and  injected  into  animals  is  capable  of 
giving     i-ise     to     an     immunity.      The 
author  suggests  that  free  receptors  ob- 
tained by  autolytic  digestion  and  filtra- 
tion of  otlier  bacteria  may  be  used  as 
a   vaccine   in   diseases   such  as  typhoid 
fever    and    d.ysentery.    Strong     (Amer. 
Med..  Aug.   15,   1003). 
Treatment. — The  treatment  of  cholera 
is  still  a  much-vexed  question,  no  specific 
remedy  having  been  found  to  directly 
combat  the  infection,  while  serum-ther- 
apy is  only  yet  in  its  incipient  stage. 
It  would  be  impossible  to  refer  to  the 
numberless   methods  which   have   been 
proposed  and  tried  with  variable  result; 
I  must,  therefore,  limit  myself  to  the 
general  rules  which  experience,  a  knowl- 
edge of  the  biology  of  the  pathogenic 
microbe,  and  of  the  influence  it  exerts 
upon  our  system  have  indicated  to  be 
the  most  rational. 

From  tliis  knowledge  tlie  aims  of  treat- 
ment would  be  as  follows:  1.  To  restrain 
the  development  of  the  germs  in  the 
intestine  and  to  neutralize  the  poisons 
to  which  tliey  give  rise  there.  2.  To 
counteract  the  poison  which  has  pene- 
trated into  the  blood-current.  3.  To 
mitigate  the  effects  of  the  twofold  (local 
and  general)  action  of  the  germs. 

1.  To  restrain  the  development  of  the 
germs  in  the  intestine  and  neutralize  the 
specific  toxins,  no  better  means  is  at  our 
disposal  tlian  acids,  whose  microbicidal 
properties  against  cholera  bacilli  are 
well  shown.  Therefore,  internal  use  of 
acids  under  the  form  of  hydrochloric, 
citric,  or  tartaric  lemonade  is  higlily  to 
be  recommended,  together  with  the  in- 
jection into  tlie  intestine,  by  means  of  a 


special  irrigator  (enteroclysma)  of  a 
warm  solution  of  tannic  acid  (1  '/<  to  5 
drachms  for  1  '/a  to  2  quarts  of  water  or 
infusion  of  chamomile).  These  injec- 
tions were  proposed  by  Cantani,  who 
gave  the  preference  to  tannic  acid  on 
account  of  its  neutralizing  the  alkaline 
reaction  of  the  intestine,  corrugating 
blood-vessels  (and  so  restraining  the  ab- 
sorption of  poisons),  and  acting  as  an 
antidote  against  the  toxins.  They  must 
be  repeated  four  times  a  daj',  and,  in 
grave  cases,  after  each  alvine  evacuation. 
The  beneficial  effects  of  this  treatment 
I  was  able  to  observe  in  the  cholera  epi- 
demic of  1884  in  Naples,  and  my  experi- 
ence is  that,  if  it  be  resorted  to  at  the 
first  appearance  of  premonitory  diar- 
rhoea, the  course  of  the  disease  may  be 
aborted,  while  in  declared  cholera  many 
lives  may  be  saved  through  its  aid,  when 
general  poisoning  has  not  yet  taken 
place.  French  authors  replace  the 
hydrochloric,  citric,  etc.,  acids  by  the 
lactic  lemonade,  prepared  with  2  Vj 
drachms  of  lactic  acid  to  a  quart  of 
water.  On  the  other  hand,  Genersich 
has  modified  Cantani's  method  by  in- 
jecting a  larger  quantity  of  fluid  (5 
to  15  quarts  of  a  1-  to  2-per-cent. 
solution  of  tannic  acid)  under  a  greater 
pressure;  so  that  the  liquid  may  irrigate 
the  whole  intestine  and  be  at  least  partly 
ejected  by  the  stomach.  This  metliod, 
to  which  he  gave  the  name  of  di/adi/sis, 
has  for  its  object  to  cause  the  remedial 
substance  to  act  upon  the  whole  mucous 
membrane  of  the  gut;  but  its  practical 
application  is  rendered  very  difficult,  and 
it  is  not  well  borne. 

Effort  to  cleanse  the  digestive  tract 
of  its  pathogenic  elements  by  the  fol- 
lowing procedure:  Every  patient  at 
once  made  to  drink  as  many  tumblerfuls 
as  possible  of  hot  water,  containing  each 
3  drops  of  hydrochloric  acid.  As  soon 
as  the  patient  had  successively  imbibed. 


150 


CHOLERA  ASIATICA.    TREATMENT. 


6  or  S  tumblerfuls,  manual  abdominal 
pressure  was  resorted  to  in  order  to  expel 
the  liquid.  Ten  minutes  after  the  vomit- 
ing had  ceased  the  whole  cleansing  pro- 
cedure was  repeated.  Sometimes  a  third 
washing  was  performed  three  hours  later. 
Simultaneously  the  intestines  were 
cleansed  by  means  of  enemata,  made  of 
from  12  to  IS  tumblerfuls  of  a  hot  2.5- 
per-cent.  aqueous  solution  of  tannin,  or, 
in  the  absence  of  the  drug,  of  the  same 
amount  of  plain,  hot  water.  The  injec- 
tion was  usually  followed  by  decrease 
of  diarrhoea:  but  sometimes  a  second 
enema  became  necessary,  being  then  ad- 
ministered about  two  hours  after  the 
first.  Wlien  practicable,  the  measures 
were  supplemented  by  a  hot  general 
bath,  and  a  successive  application  of  ab- 
dominal compresses  soaked  iu  hot,  strong 
solution  of  kitchen-salt,  and  wrapping 
the  whole  body  with  hot  sheets  and 
blankets.  Internally,  the  patients  were 
given  claret  (boiled  with  cinnamon  and 
sugar)  and  lemonade  made  of  hydro- 
chloric acid  (10  drops  to  each  tumbler- 
ful), a  mouthful  every  ten  minutes.  In 
addition,  some  stimulant  remedy  (cam- 
phor, ether,  caffeine  with  benzoate  of 
sodium)  was  administered  hypodermic- 
ally.  But  10  cases  out  of  00  thus  treated 
lost.  I.  F.  Shorr  (Yujno-Riisskoia  Med. 
Gaz.,  No.  13,  '92). 

Introduction  of  a  soft-rubber  tube  one 
metre  in  length  into  the  rectum,  causing 
it  to  pass  through  the  sigmoid  fle.xure 
and  enter  the  descending  colon,  and  carry 
liquid  as  far,  at  least,  as  the  ileo-ca;cal 
valve.  A  large  quantity  (2  or  3  gallons) 
of  warm  soap-water  tlius  introduced  ef- 
fectively cleanses  the  intestinal  canal; 
the  secondary  elTeot  of  irrigation  of  the 
colon  is  to  cleanse  and  relieve  the  small 
intestine  of  its  contents.  Of  20  eases 
thus  treated,  23  recovered.  Elmer  Lee 
(Med.  Rec,  Dec.  17,  '92). 

Experiments  carried  out  with  a  view 
of  determining  the  competency  of  the 
ileo-cojcal  valve,  showing  that  in  a  cer- 
tain number  of  cases  success  may  be 
looked  for,  even  though  the  first  attempt 
prove  a  failure.  In  four  cases  there  was 
no  difTleulty  whatever  in  the  passage  of 
liquids  from  the  anus  to  the  stomach  or 
even  out  through  tlie  mouth  and  nose. 


Judson  Daland   (Amer.  Jour.  Med.  Sci., 
July,  '93). 

Choleraic  patients  obtain  real  benefit 
from  the  use  of  tar-water  given  inter- 
nally, in   small   quantities,  and   in   the 
form  of  enemata.     It  generally  arrests 
violent  diarrhoea  and  vomiting,  and  im- 
proves   the    bicn-ctre    of    the    patients. 
Polubinski  (Wratsch,  No.  50,  '92). 
For  the  purpose  of  cleansing  the  in- 
testine of  the  specific  germs,  and  their 
noxious  products,  the  use  of  purgatives 
has  been  recommended,  especially  in  the 
first  stages  of  the  disease;    calomel  and 
castor-oil  are  generally  preferred,   and 
they  may  sometimes  give  good  results. 
But,  when  they  do  not  act  favorably  on 
the  first  or  second  day,  their  efl'ect  can 
no  longer  be  relied  upon. 

Attention  drawn  to  the  views  held  by 
many,  viz.:  the  risk  that  attends  the 
use  of  purgative  medicines,  and  salines 
especially,  during  periods  of  epidemic 
cholera,  and  at  places  where  that  disease 
happens  to  be  prevailing.  Physicians 
who  practice  in  India  seem  to  have  recog- 
nized the  danger  of  strong  purgatives. 
Editorial   (Lancet,  Sept.  23,  '93). 

[A  large  number  of  cases  seen  in 
which,  under  appropriate  treatment, 
purging  and  vomiting  had  been  stopped, 
and  the  patients  apparently  recovered, 
but  who  were  afterward  brought  back 
to  a  fatal  state  of  collapse  by  the  admin- 
istration of  purgatives  of  an  in-itating 
nature.    Neve,  Corr.  Ed.,  Annual,  '94.J 

3.  To  counteract  the  effects  of  poisons 
absorbed  into  the  blood  we  have  no  effi- 
cient means,  the  greater  number  of 
drugs  given  for  tliis  purpose  (especially 
antiseptics)  having  failed  or  given  but 
very  imperfect  results.  The  only  thing 
we  can  do  is  not  to  exert  an  antidotal 
action  upon  them,  but  to  hasten  and 
make  easy  their  elimination  from  the 
blood,  by  largely  diluting  it  through  the 
introduction  of  an  artificial  scrum,  a 
practice  answering  other  important  ob- 
jects, as  we  shall  see  shortly. 

3.  Among  the  noxious  effects  of  local 


CHOLERA  ASIATICA.    TREATMENT. 


151 


inflammation  and  of  tlie  general  tox- 
aemia, which  require  an  energetic  treat- 
ment, the  principal  are:  diarrhoea  and 
vomiting,  with  excessive  loss  of  watery 
fluids;  and  danger  of  heart-paralysis. 

To  control  diarrhoea  and  vomiting, 
when  excessive,  is  a  vital  indication,  the 
profuse  loss  of  water  they  involve  con- 
tributing a  very  serious  danger  for  the 
organism.  Against  diarrhrea,  the  same 
rectal  injections  of  tannic-acid  or  ace- 
tate-of-lead  solutions  and  internal  use 
of  opium. 

As  a  person  shows  the  premonitory 
symptoms  of  cholera,  by  having  one  or 
two  large  watei-y  motions  passed  with 
little  or  no  pain,  and  begins  to  vomit, 
it  is  best  to  put  him  under  the  influence 
of  opium  at  once.  All  physicians  who 
have  had  much  to  do  with  the  treatment 
of  cholera  in  India  are  agreed  in  this; 
and  it  is  noteworthy  that  many  so- 
called  cholera  "specifics,"  which  have 
from  time  to  time  been  popular,  contain 
opium  in  some  form.  F.  C.  Nicholson 
(Practitioner,  Sept.,  '93). 

Carbonate  of  calcium,  salicylate  of 
bismuth,  etc.,  may  also  be  of  some  serv- 
ice; while,  to  subdue  the  vomiting  and 
painful  cramps  in  the  stomach,  ice, 
laudanum,  morphine  (hypodermically), 
cocaine,  chlorodyne,  essence  of  mint, 
menthol,  camphor,  or  chamomile  may 
be  resorted  to. 

Belladonna  advocated.  lllingworth 
(Med.  Press  and  Circular,  June  19,  '93). 
Atropine  most  useful  on  account  of 
the  control  that  it  would  exercise  over 
the  cramps  of  the  muscles  and  in  spasm 
of  the  bile-duct.  Scriven  (Brit.  Med. 
Jour.,  June,  '93). 

Atropine  of  marked  value  in  collapse. 
Lauder  Brunton  (Brit.  Med.  Jour.,  June, 
'93). 

Shortly  after  the  development  of  first 
symptoms  a  subcutaneous  injection  of 
camphor,  with  musk,  is  rapidly  followed 
by  a  striking  ti melioration  in  the  pa- 
tient's condition,  vomiting  cither  greatly 
decreasing  or  ceasing  altogether,  the  well- 


known  distressing  oppression  about  the 
chest  similarly  subsiding.  PopofT  (In- 
aug.  Dis.,  No.  25,  p.  55,  '93). 

Blisters  to  the  neck,  along  the  course 
of  vagus,  cause  both  vomiting  and  hic- 
cough to  cease.  BlagovidofI  (Wratsch, 
No.  34,  '92). 

The     following     treatment    employed 
with  advantage,  particularly  for  the  re- 
lief of  the  cramps  and  vomiting:  — 
R  Dilute  hydrochloric  acid,  15  minims. 
Pure  pepsin  essence,  20  minims. 
Wine  of  opium,  20  minims. 
Peppermint-water,  4  ounces. 
■    Syrup  of  orange-flower,  1  ounce. 
M.     Sig. :    A  teaspoonful  each  hour. 
This  dose  can  be  diminished  as  soon 
as  the  medicine  controls  the  attack  to 
some  extent,  so  that  4  teaspooufuls  a  day 
may  be  suflicient.    Sometimes  15  minims 
of  ether  may  be  added  to  this  mixture 
with    advantage.      Chauvin     (La    Mfid. 
Mod.,  Sept.  5,  '90). 

But  the  effects  of  these  remedies  are 
only  transient,  and  the  use  of  some  of 
them— especially  morphine — should  not 
be  prolonged,  in  order  to  avoid  the  dan- 
ger of  increasing  the  general  depression. 
Solutions  of  benzoyl-acetyl  peroxide 
are  extremely  active  as  germicides.  In 
cholera  it  was  at  first  given  by  mouth 
as  frequently  as  possible  in  sobition  of 
1  to  1000,  and  by  high  rectal  injec- 
tions every  six  hours.  For  stimulation, 
brandy  and  strychnine  were  given  hypo- 
dermically, and,  if  the  general  condition 
of  the  patient  was  good,  morphine  was 
sometimes  given  to  relieve  pain.  Tur- 
pentine stupes  and  hot-water  bags  were 
also  used  to  relieve  pain.  Vomiting  was 
generally  stopped  by  cocaine  and  cracked 
ice.  In  some  hospitals  the  administra- 
tion of  double  gelatin  capsules  contain- 
ing each  0.25  gramme  (4  grains)  of  ben- 
zoyl-acetyl peroxide  was  resorted  to,  as 
it  was  found  that  the  continued  admin- 
istration of  solutions  per  OS  produced 
vomiting.  The  high  rectal  injections 
form  an  important  part  of  the  treat- 
ment, especially  in  the  second  stage, 
when  the  bowel  movements  are  approxi- 
mately few,  because  the  colon  then  con- 
tains a  large  amount  of  toxin  which  is 


152 


CHOLERA  ASIATICA.    TREATMENT. 


flushed  out  by  this  means.  Omitting 
deaths  occurring  immediately  after  ad- 
mission to  the  hospital,  and  counting 
only  those  occurring  six  hours  or  more 
after  admission,  the  mortality  in  one 
hundred  and  twenty  cases  was  45.71  per 
cent.  The  native  mortality  was  prob- 
ably increased,  owing  to  the  difficulty  in 
inducing  native  patients  to  take  any 
medicine  at  all.  Of  six  Americans 
treated,  four  recovered  and  two  died. 
P.  C.  Freer  (Government  Lab.  Bull.,  No. 
2,  1902;   Med.  News,  Feb.  21,  1903). 

When  diarrhoea  and  vomiting  are  un- 
restrainable,  and  therefore  loss  of  water 
is  so  large  as  to  cause  a  rapid  thicken- 
ing of  the  blood  and  drying  of  the  tis- 
sues, an  attempt  must  be  made  to  re- 
store, as  much  as  possible,  the  normal 
composition  of  the  blood,  to  render  it 
more  fluid  and  to  make  circulation  and 
hsematosis  easier.  For  this  purpose  sub- 
cutaneous injections  of  a  hot,  saline 
solution  were  proposed  by  Cantani  and 
Samuel  and  experimented  on  a  very 
large  scale  and  with  very  good  effects 
by  many  physicians  and  by  the  writer. 
Cantani's  formula  is  as  follows:  Dis- 
tilled water,  1  quart;  chloride  of  sodium, 
1  drachm;  carbonate  of  sodium,  45 
grains.  Of  this  solution,  warmed  to 
100.4°  to  104°  F.,  one  or  two  quarts  are 
injected  into  the  subcutaneous  tissue  of 
the  flanks.  The  results  of  this  method 
are  most  striking,  sometimes  even  in  the 
algid  stage;  and,  if  it  does  not  always 
save  life,  it  at  least  gives  tlie  patient 
some  relief  from  his  sufferings.  Its 
effect  is  shown  by  removing  cardiac 
weakness  and  feebleness  of  the  pulse,  by 
bringing  on  the  secretion  of  urine,  by 
elevation  of  temperature,  etc. 

Intravenous  infusions  of  Ilayem's 
artificial  serum  (distilled  water,  1  quart; 
chloride  of  sodium,  100  grains;  hydrate 
of  sodium,  20  grains;  sulphate  of  so- 
dium, 1  ounce)  are  equally  beneficial, 
but    their    use    is    more    difficult,    and 


they  are  no  more  prompt  in  their  effects 
and  not  without  danger.  The  subcu- 
taneous injections  are,  therefore,  gener- 
ally preferable. 

Case  of  cholera  in  which  intravenous 
injections  of  salt  solution  were  followed 
by  resuscitation  sufficient  to  allow  the 
patient  to  sit  up  and  make  a  will.    The 
operation  was  repeated  six  times,  and  it 
was  noted  that  good  eft'eet  could  only  be 
obtained  when  the  venous  system  was 
rapidly    distended.      Richardson    (Ascle- 
piad,  No.  4,  '91). 
To  avoid  the  danger  of  heart-paral- 
ysis, so  far  as  this  depends  upon  the 
thickening  of  the  blood  and  the  empti- 
ness of  the  vessels,  we  may  have  recourse 
to  the  same  watery  injections;    but  if 
they  do  not  succeed,  and  whenever  car- 
diac weakness  is  directly  produced  by 
the  action  of  the  toxins,  the  heart  must 
be  stimulated  by  hypodermic  injections 
of    sulphuric    ether,    camphorated    oil, 
caffeine,  strychnine,  or  quinine. 

Quinine  recommended,  1 V.  grains  given 
every  2  hours  for  24  hours,  and  repeated 
during  a  second  24  hours  it  necessary. 
If  vomiting  be  present  and  beyond  con- 
trol, the  drug  should  be  injected  beneath 
the  skin.  Huberwald  (Jahrbuoh  fUr 
Kinderh.  u.  phys.  Erziehung,  B.  35,  H.  3, 
'93). 

Treatment  adopted  in  944  cases  with 
a  mortality  of  only  20.7  per  cent.    1.  (o) 
Internal  administration  of  Botkin's  anti- 
cholera  drops: — 
IJ  Tincturro  quinines  compositas, 

Spiritus  anodyni  HolTmaimi,  of  each, 

V=  ounce. 
Quinina:  hydroohlorici,  1  drachm. 
Acidi  hydrochlorici  diluti,  '/..  drachm. 
Tincturce  opii  simplicia,  1  drachm. 
Olei  monthro  piperita;,  10  drops. 
M.     Sig.:    Give  from   15  to  20  drops 
every  two  hours. 

(/>)  Caniani's  higli  eneniata  with  tannic 
acid;  (c)  internal  use  of  salol  with  sub- 
nitrate  of  bismuth;  {(I)  calomel  in  small 
doacs. 

2.  In  severe  cases  stimulate  and  sus- 
tain the  cardiac  and  cutaneous  action: 
Repeated    and    prolonged    general    hot 


CHOLERA  ASIATICA.     TREATMENT. 


153 


baths,  heating  tlie  patient's  body  by  any 
available  means;  free  administration  of 
wine,  hot  tea,  or  cofTee  with  brandy; 
and  subcutaneous  injections  of  camphor. 
SokolofT  (Bolnitchnaja  gazeta  Botkina, 
Nos.  1,  2,  '93). 

Large  doses  of  quinine,  15  to  20 
grains  administered  early,  found  to 
cheek  the  vomiting  and  purging  in  an 
hour  or  two.  Tlie  administration  must 
be  by  the  mouth,  and  not  by  subcu- 
taneous injection.  E.  B.  FuUerton 
(Medical  Record,  April  25,  1903). 

The  internal  use  of  brandy,  rum, 
champagne,  liquor  ammonia,  inhala- 
tions of  oxygen,  etc.,  may  also  prove  of 
advantage  in  cardiac  failure. 

Ammonia  internally  and  ether  hypo- 
dermically,  besides  the  free  administra- 
tion of  alcohol,  highly  recommended,  the 
aim  being  to  support  the  failing  heart. 
Giaeich  (Berliner  klin.  W()ch.,Sept.5,'92). 
Hydrochlorate  of  ammonia  recom- 
mended for  the  same  pui-pose.  Besides 
the  return  of  heat  and  perspiration 
caused  by  this  salt,  it  increases  diuresis, 
and  therefore  increases  the  elimination 
of  the  toxic  elements  of  the  disease. 
Dumontpallier  (Le  Bull.  IMOd.,  Oct.  19, 
'92). 

For  the  same  purpose,  and  to  restore 
the  warmth  of  the  skin,  hot  baths  (sim- 
ple or  sprinkled  with  mustard)  and  the 
application  of  heat  in  every  form  (warm 
coverings,  hot-water  bottles  or  hot  bricks 
around  the  body,  Turkish  baths,  etc.), 
dry,  energetic  frictions,  application  of 
sinapisms,  electric  flagellations,  etc., 
have  proved  very  valuable. 

The  state  of  the  bladder  should  be 
carefully  watched,  and  if  examination 
shows  the  presence  of  residual  urine,  it 
should  be  emptied  through  the  catheter. 
True  choleraic  anuria  is  best  combated 
by  hot,  exciting  drinks,  hot  baths, 
and  hypodermic  injections  of  caffeine 
and  pilocarpine,  a  solution  of  the  latter 
of  Vs  ^ain  to  20  minims  of  distilled 
water  being  employed. 

During   the   whole   disease    no    food 


should  be  allowed  to  patients;  at  the 
most,  if  any  food  is  believed  necessary 
and  the  stomach  is  not  altogether  in- 
tolerant, some  iced  milk  can  be  given. 

The  treatment  of  the  period  of  reac- 
tion, when  it  runs  a  regular  course,  is 
only  a  hygienic  one.  Feeding  must  be 
carefully  regulated,  only  liquid  food 
being  allowed  the  first  few  days,  then 
passing  gradually  to  more  substantial 
nourishment.  'ttTien,  however,  the  dis- 
ease assumes  the  typhoid  form,  hygienic 
rules  must  be  assisted  by  symptomatic 
treatment;  if  adynamia  supervene,  cold 
packs  and  stimulants  must  be  used; 
when,  on  the  contrary,  symptoms  of 
nervous  excitement  prevail,  lukewarm 
baths  with  cold  affusions  on  the  head, 
afford  great  relief.  Cerebral  congestion 
is  best  combated  by  the  application  of 
ice  to  the  head,  by  local  blood-letting, 
etc. 

Hydrotherapy  successful  in  curing  a 
large  number  of  patients  already  sufTer- 
ing  from  cramp  in  the  calves,  vomiting, 
cold  extremities,  and  discolored  stools. 
Friction  of  the  skin  with  a  piece  of  linen 
soaked  in  the  coldest  water;  then  a 
sitz-bath,  at  a  temperature  of  44.4°  to  59° 
F.  during  fifteen  or  thirty  minutes.  The 
parts  of  the  body  not  in  contact  with 
the  cold  water  are  enveloped  in  woolen 
coverings,  and  the  abdomen  is  energetic- 
ally rubbed.  Winternitz  (Blatter  f.  klin. 
Hydrotherapie,  etc.,  Oct.  10,  '92). 

By  rubbing  the  affected  areas  with  a 
piece  of  ice,  cramps — an  excruciating 
syiTiptom — are  relieved  with  rapidity. 
Pasalsky  (Provincial  Med.  Jour.,  Nov. 
1,  '03). 

Salol  is  an  excellent  remedy  against 
choleraic  diarrhoea,  provided  it  is  ad- 
ministered in  larger  doses  than  are  usu- 
ally given;  2  to  2'/.  drachms  during  the 
24  hours,  30  grains  to  begin  with,  fol- 
lowed every  3  hours  by  a  dose  of  15 
grains.  Walkowitch  (La  Sem.  Mfd.,  No. 
5G,  '93). 

Salol  in  5-grain  doses  recommended, 
repeated  hourly  as  long  as  required  by 
the  necessities   of  the  case.     The  drug 


154 


CHOLERA  ASIATICA.     CHOLERA  NOSTRAS. 


mitigates  all  choleraic  symptoms.  Piat- 
nitzky  (Inaug.  Dis.,  No.  S,  p.  97,  '93). 
Against  hyperthermia  and  general 
poisoning  quinine  by  hypodermic  injec- 
tions should  be  resorted  to.  Gastro-in- 
testinal  disorders  (tjTnpanites,  abdominal 
pains,  fcetid  diarrhoea)  must  be  treated 
by  cold  applications  to  the  abdomen,  by 
internal  use  of  calomel,  and  by  rectal 
injections  of  detergent  and  disinfecting 
solutions  (hyposulphite  of  sodium  2  to 

5  to  1000,  boric  acid  and  tannic  acid, 

6  to  10  to  1000),  etc. 

Fifty-one  cases  with  but  5  deaths 
under  immediate  use  of  calomel,  not 
forgetting  to  give  hydrochloric  acid  at 
the  same  time.  The  calomel  is  mixed 
with  a  little  water  and  gum  powder, 
placing  the  mixture  on  the  tongue,  thus 
avoiding  touching  the  teeth.  The  first 
dose  is  15  Vi  grains,  repeated  several 
times.  Opium  avoided.  Van  Hasselt 
(Nederlandsch  Tyd.  voor  Genees.,  vol. 
xxxii,  '03). 

The  administration  of  calomel  in  doses 
of  '/j  to  1  grain  strongly  advocated, 
given  every  hour.  Treynmnn  (Med. 
Press  and  Circular,  Apr.  19,  '93). 

Calhoun  many  years  ago  obtained  far 
superior  results  to  those  reported.  He 
prescribed  calomel,  10  grains;  gum  cam- 
phor and  tannin,  each  5  grains;  every 
half-hour  or  hour,  as  the  urgency  of  the 
symptoms  demanded,  until  the  diarrhoea 
was  checked  and  the  secretions  restored 
to  a  healthy  state.  In  combination  with 
the  above  substances  he  occasionally  pre- 
scribed opium.  F.  Peyre  Porcher  (Med. 
Rec,  Nov.  26,  '92). 

Calomel  most  highly  recommended  as 
far  back  as  185.^,  beginning  its  use  as 
soon  as  the  choleraic  diarrhoea  appeared. 
Two  or  three  doses  of  7  'A  grains  each  are 
administered,  followed  by  small  doses  of 
V»  grain  every  two  hours.  A  portion  of 
the  calomel  becomes  changed  in  the  in- 
testine to  corrosive  sublimate;  and  as 
corrosivc-Hublimate  solutions  have  a  fun- 
gus-destroying action  in  a  strength  of  1 
to  30,000,  it  is  easy  to  believe  that  the 
bacilli  in  the  intestine  arc  directly  killed 
by  the  calomel.  Ziemssen  (Ther.  Gaz., 
Mar.  15,  '93). 


During  this  period,  activity  of  the 
blood  must  be  guarded  against;  and  to 
this  end  enteroclysis  with  a  salt  solu- 
tion of  10  or  15  per  cent,  is  very  useful, 
and,  if  need  be,  hypodermoclysis  with 
Cantani's  solution  can  be  continued. 

Cholera  Nostras. 

This  form  of  cholera  resembles  very 
closely  Asiatic  cholera  in  its  clinical 
aspects;  so  that  the  distinction  between 
the  two  diseases  is  sometimes  most  dif- 
ficult. Many  authors,  indeed,  believe  in 
their  identity.  Guerin,  for  example, 
claimed  that  cholera  is  always  the  same 
disease  in  every  place,  and  that  isolated 
cases,  such  as  are  met  with  every  year 
in  Italy,  in  the  hot  season,  are  identical 
to  those  which  are  developed  in  India. 
Leyden,  also,  does  not  think  that  there 
is  a  wide  difference  between  cholera 
nostras  and  Asiatic  cholera.  Lastly, 
Talamon  argues  in  favor  of  their  identity, 
basing  his  theory  on  the  fact  that  epi- 
demics of  choleriform  diarrhoea  occur 
from  time  to  time  without  its  being  pos- 
sible to  attribute  them  to  importation, 
in  places  where  true  .cholera  had  been 
previously  observed.  This  author  refers 
to  two  epidemics  in  the  neighborhood  of 
Paris,  which  had  been  recognized  as 
cholera  nostras,  but  in  which  the  bac- 
teriological investigation  had  plainly 
shown  the  presence  of  the  comma  ba- 
cillus. 

On  the  other  hand,  several  authors 
hold  the  view  that  cholera  nostras  is  a 
disease  etiologically  different  from  Asi- 
atic cholera,  appearing  generally  in  spo- 
radic cases,  but  sometimes  becoming  epi- 
demic. It  is  produced  very  often  by 
dietetic  errors,  or  by  the  action  of  cold, 
or  by  the  ingestion  of  iced  draughts  in 
persons  exposed  to  intense  heat. 

Tinkler  and  Prior  found  in  the  stools 
of  patients  affected  with  cholera  nostras 
an  organism  in  the  sliape  of  a  comma 


CHOLKRA  ASIATICA. 


CHOLERA  INFANTUM. 


155 


bacillus,  and  therefore  greatly  resem- 
bling the  cholera  vibrio.  It  differs  from 
the  latter,  however,  by  the  fact  that, 
when  cultivated  in  gelatin,  it  very  soon 
becomes  liquefied,  and  does  not  give  the 
cholera-red  reaction.  But  in  many  cases, 
instead  of  the  vibrio  of  Finkler  and 
Prior,  other  organisms  (bacillus  subtilis, 
bacterium  coli  commune)  have  been 
found;  so  that  the  etiological  question 
is  still  unsettled  and  no  decided  opinion 
can  be  formed  about  the  real  nature  of 
cholera  nostras. 

Symptoms  of  cholera  nostras  are  very 
'like  those  of  Asiatic  cholera;  very  often, 
however,  the  stools  are  not  riziform,  but 
bilious  and  serous;  vomiting  is  not  com- 
.  mon,  and  cooling  of  the  skin  does  not 
reach  an  advanced  degree.  Moreover, 
the  period  of  reaction  is  not  accom- 
panied by  the  serious  inflammatory 
changes  which  are  so  common  in  Asiatic 
cholera;  finally,  the  disease  shows  a 
more  marked  dependence  upon  seasonal 
influences.  When  cholera  nostras  ends 
in  death,  this  takes  place  after  the  signs 
of  collapse  have  grown  progressively 
worse  in  persons  weakened  by  previous 
illness  or  in  children  and  old  people. 
Generally  the  disease  lasts  only  twenty- 
four  to  forty-eight  hours;  then  convales- 
cence ensues,  leaving  often  a  feeling  of 
extreme  weakness. 

The  treatment  of  cholera  nostras  is 
essentially  the  same  as  in  Asiatic  cholera; 
and  prophylactic  measures  are  of  no  less 
practical  import,  though  the  contagious- 
ness of  cholera  nostras  does  not  seem  to 
be  as  great  as  that  of  Asiatic  cholera. 
(See  CiioLEn.\  JIorbus.) 

A.  Ri'iuNO, 

Naples. 

CHOLERA  INFANTUM.. 

Definition. — A  particularly  grave  form 
of  infantile  diarrhrca,  with  sjTnptoms 
closely  resembling  those  of  true  cholera; 


frequent  persistent  vomiting,  copiouB 
serous  dejections,  high  fever,  and  a  rap- 
idly-developing condition  of  profound 
collapse. 

It  is  a  comparativelj'-rare  disorder, 
forming  not  more  than  from  V;  to  2  per 
cent,  of  all  the  diarrhccal  cases  met  with 
during  the  summer  months.  Unfortu- 
nately for  the  accuracy  of  our  statistics, 
the  term  has  been  applied  indiscrim- 
inately to  all  cases  of  severe  infantile 
diarrhoea.  In  the  opinion  of  the  best 
writers  the  name  shoidd  be  limited  to 
such  cases  as  are  characterized  by  intense 
choleriform  symptoms. 

[Intelligent  work  upon  this  subject  is 
still  greatly  impeded  by  coufusion  in  no- 
menclature. Many  excellent  articles  are 
diminished  in  value  or  rendered  actually 
worthless  by  the  indiscriminate  use  of 
the  terms  "cholera  infantum,"  "enteritis," 
and  other  indefinite  expressions,  render- 
ing it  impossible  to  determine  the  form 
of  disease  to  wliicli  the  author  refers. 
The  term  "cholera  infantum"  is  the  one 
most  frequently  used  incorrectly.  It  Is 
limited  by  nearly  every  author  of  promi- 
nence to  cases  characterized  by  large, 
serous  stools,  accompanied  by  profuse 
vomiting,  high  temperature,  prostration, 
and  marked  nervous  symptoms.  If 
writers  for  the  journals  would  observe 
the  same  rule  it  would  save  very  much 
confusion,  and  render  their  work  of 
decidedly  more  value.  Holt  and  Cran- 
DALL,  Assoc.  Eds.,  Annual,  '92.] 

Symptoms. — After  a  variable,  but  gen- 
erally brief,  period,  characterized  by  rest- 
lessness, abdominal  discomfort,  and  a 
rising  temperature,  the  infant  begins  to 
vomit,  and  simultaneously  or  shortly  af- 
terward purging  commences.  The  vom- 
iting recurs  frequently.  At  first,  the  con- 
tents of  the  stomach  are  ejected;  then 
a  bile-stained  mucus;  and,  lastly,  noth- 
ing but  a  serous  fluid.  The  evacuations 
from  the  bowels  soon  assume  the  same 
serous  character.  They  lose  their  faecal 
appearance  and  acid  reaction,  and  con- 


156 


CHOLERA  INFANTUM.     SYJlPTOilS.     DIAGNOSIS. 


sist  almost  entirely  of  a  colorless  fluid, 
copious  in  amount,  alkaline  in  reaction, 
and  generally  with,  a  peculiar  musty  odor. 
Examined  microscopicall)',  little  has 
been  found  in  this  fluid  beyond  a  large 
amount  of  epithelial  debris,  some  round 
cells,  and  numerous  bacteria.  Such  dis- 
charges soak  into  the  diapers,  leaving  al- 
most no  stain  and  scarcely  any  ftecal  mat- 
ter to  indicate  that  the  fluid  has  come 
from  the  intestines.  Although  these 
evacuations  are  very  frequent,  recurring 
every  half-hour  or  hour,  pain  is  not  gen- 
erally a  marked  feature. 

The  temperature  taken  in  the  rectum 
is  always  elevated,  generally  between 
103°  F.  and  105°  F.;  nevertheless  the 
body  feels  cool  to  the  hand.  Thirst  is 
extreme;  but  liquids  and  foods  of  all 
kinds  are  rejected  by  the  stomach  shortly 
after  they  are  taken.  "With  such  a  drain 
upon  the  fluids  of  the  body  the  infant 
rapidly  loses  weight  and  strength,  and 
in  a  few  hours  its  appearance  is  greatly 
altered.  The  face  is  of  an  ashy  pallor, 
the  eyes  sunken,  the  features  pinched, 
and  the  expression  anxious.  The  open 
fontanelle  is  much  depressed;  the  pulse 
is  quick  and  weak  and  may  be  intermit- 
tent; the  urine  is  scanty  and  in  severe 
cases  appears  to  be  altogether  suppressed. 

During  the  earlier  hours  of  the  dis- 
ease restlessness  is  a  marked  symptom; 
but,  as  the  strength  fails,  this  is  gradu- 
ally replaced  by  a  condition  of  apathy, 
which,  later  on,  may  develop  into  the 
hydrenccpbaloid  state:  the  spurious  hy- 
drocephalus of  older  writers.  Should  the 
disease  take  this  course,  the  infant  will 
be  found  lying  in  a  semicomatose  condi- 
tion, with  head  drawn  backward,  pupils 
sluggish  and  sometimes  unequal,  abdo- 
men retracted,  and  respiration  possibly 
irregular  and  of  the  Chcyne-Stokes  type. 
There  may  also  be  twitching  of  the  arms 
and  legs.    Toward  the  end  the  infant  be- 


comes more  comatose,  or  an  attack  of 
conviilsions  may  supervene  and  usher  in 
the  close. 

In  some  cases  a  condition  of  hyper-- 
pyrexia  may  precede  the  fatal  termina- 
tion. In  others,  the  high  temperature  of 
the  earlier  hours  may  pass  away  and  a 
more  moderate  pyrexia,  or  even,  accord- 
ing to  some  writers,  a  normal  or  sub- 
normal temperature  take  its  place.  Nev- 
ertheless, if  the  graver  symptoms  of  col- 
lapse persist,  this  fall  must  be  regarded  ' 
as  an  unfavorable  omen.  In  such  cases 
we  sometimes  find  that  both  vomiting 
and  purging  cease  a  few  hours  before  the 
end  occurs. 

The  course  of  this  disease  is  very  rapid, 
terminating  in  many  cases  in  collapse 
and  death  within  twenty-four  or  forty- 
eight  hours  after  its  commencement. 
Should  hydrencephaloid  symptoms  set 
in,  the  end  may  be  delayed  for  a  day  or 
two  longer.  In  the  few  cases  which  go 
on  to  recovery,  cessation  of  vomiting  ap- 
pears to  be  one  of  the  earliest  symptoms 
of  improvement;  gradually  the  char- 
acter of  the  stools  alters,  and  they  be- 
come more  faecal;  the  restlessness  abates, 
and  improvement  may  be  noted  in  the 
pulse  and  general  appearance  of  the  in- 
fant. Convalescence,  however,  is  always 
tardy,  and  relapses  are  not  uncommon. 
Diaifnosis.- — The  character  of  the  on- 
set, the  persistent  vomiting,  the  profuse 
serous  dejections,  the  high  temperature, 
and  the  symptoms  of  profound  collapse 
rapidly  developing  within  a  few  hours, 
form  a  picture  unlikely  to  be  mistaken 
for  any  other  condition. 

Tlie  odor  of  t,hc  stools  makes  it  pos- 
sible to  deteriiiiiio  two  general  classes  of 
fermentation.  The  fermentation  of  the 
carbohydrate  foods  leads  to  the  develop- 
ment of  acids  and  gases,  but  under  no 
circumstances  to  products  with  a  putrid 
odor.  Proteids  yield  either  odorless  or 
putrid  products.  Fitch  (Va.  Med.  Mthly., 
Mar.,  '94). 


CHOLERA  INFANTUM.    ETIOLOGY. 


157 


Etiology. — The  exact  nature  of  cholera 
infantum  has  not  yet  been  proved,  but 
analogy  points  strongly  to  its  being  a 
toxic  condition  produced  by  the  absorp- 
tion from  the  intestinal  tract  of  some 
special  toxin  originating  in  fermenting 
or  decomposing  food.  The  prolonged 
heat  of  July  and  August  appears  to  be 
a  distinctly  predisposing  factor.  Infants 
living  under  faulty  hygienic  conditions, 
and  supplied  either  with  an  injudicious 
dietary  or  with  milk  food  in  the  prepara- 
tion of  which  due  care  has  not  been 
taken,  appear  to  be  among  those  most 
prone  to  attack.  Although  the  disease 
may  develop  suddenly  in  the  compara- 
tively healthy,  yet  we  find  that,  in  the 
majority  of  cases,  there  has  been  a  more 
or  less  severe  antecedent  disorder  of  the 
gastro-intestinal  tract. 

From  22  observations,  the  following 
conclusions  are  drawn:  (1)  the  spores 
present  in  acute  dyspepsia  and  intro- 
duced with  the  food  will  grow  luxuri- 
antly at  the  body-teniperatui-e,  and  these 
are  capable  of  withstanding  the  action 
of  the  acids  of  the  stomach;  (2)  since 
severe  dyspepsias,  especially  of  the  chol- 
era-infantum  type,  present  the  phenom- 
ena of  acute  intoxication,  and  increase 
in  severity  with  the  temperature  of  the 
atmosphere,  their  cause  is  to  be  sought 
in  the  poisons  generated  by  the  sapro- 
phytic germs  of  the  stomach  and  intes- 
tines; (3)  some  of  these  cases  have  the 
general  characteristics  of  acute  infectious 
diseases  in  their  etiology,  but  the  ma- 
jority are  not  particularly  endemic  or 
epidemic,  and  the  special  characteristics 
of  infectious  diseases  (stage  of  incuba- 
tion, typical  course,  etc.)  are  rare.  Seif- 
fert  (Jahrbuch  f.  Kinderh.  u.  physische 
Erziehung,  B.  32,  H.  4,  '91). 

\.  When  the  heat  rises  above  10.7°  F. 
the  galactozymose,  or  starch-liquefying 
ferment,  is  destroyed.  It  is  present  in 
cows'  milk  only  in  minute  quantities. 
2.  A  portion  of  the  lactalbumin  is  coagu- 
lated. 3.  The  casein,  after  the  action  of 
prolonged  heat,  is  less  readily  coagulated 
by  rennet,  and  yields  slowly  and  imper- 


fectly to  the  action  of  pepsin  and  pan- 
creatin.  4.  Fat  is  so  affected  by  the 
heat  that,  after  the  milk  has  stood  for 
some  time,  small  lumps  collect  on  the 
surface.  5.  Milk-sugar  is  completely  de- 
stroyed by  prolonged  heating.  Leeds  and 
Hiesland  (X.  Y.  Med.  Jour.,  Nov.  7, '91). 
Careful  bacterial  examinations  of  the 
stools  in  ninety-two  different  cases  of 
various  degiees  of  intensity,  and  in  the 
fatal  cases  similar  examinations  of  the 
intestinal  contents  and  of  the  various 
internal  organs,  were  coupled  with  his- 
tological examinations  with  a  view  to 
determining  the  relation  of  the  intestinal 
infections  and  lesions  to  the  remoter 
changes  in  the  body.  Conclusion  that 
the  intestinal  disorders  of  children  are 
to  be  attributed  to  no  one  specific  form 
of  bacteria.  That  in  many  cases  the 
actual  damage  is  done  more  by  the  prod- 
ucts of  the  bacterial  growth  than  by 
the  germs  themselves  seems  clear,  since 
we  know  that  these  products  are  often 
strongly  toxic,  and  since  in  many  even 
fatal  cases  no  penetration  of  the  body- 
tissues  by  the  bacteria  can  be  demon- 
strated. In  the  milder  forms  of  these 
disorders  it  is  not  unlikely  that  the 
acids,  which  Baginsky  has  shown  are 
generated  by  the  obligatory  milk-fajces 
bacteria  in  moderate  quantity  even  under 
normal  conditions  may  be  the  irritant 
of  the  intestinal  mucous  membrane 
chiefly  responsible  for  the  symptoms; 
and  this  conception  seems  fully  in  accord 
with  the  decided  acidity  of  the  stools  in 
these  cases.  In  the  severer  cases,  and 
particularly  when  pj'ogenic  or  necrotiz- 
ing species  of  bacteria  are  present,  dis- 
tinct inflammatory  changes  in  the  intes- 
tinal mucosa  are  usually  present  and 
seem  often  to  pcnnit  the  entry  of  the 
bacteria  to  the  underlying  tissues, 
whence  they  may  be  disseminated 
throughout  the  body  and  induce  a  gen- 
eral pyajmic  condition  of  which  pneu- 
monia is  not  an  infrequent  manifesta- 
tion. Booker  (Johns  Hopkins  Hosp.  Re- 
ports, vol.  vi.  159,  '00). 

The  diarrheal  disorders  of  childhood 
occurring  in  conjunction  with  elevated 
summer  temperature  appear  first  as 
functional  (chemical)  disturbances  and 
subsequently  as  profound  organic  lesions 


158 


CHOLERA  INFANTUM.     PATHOLOGY. 


of  the  intestinal  wall.  For  the  develop- 
ment of  these  conditions  the  ordinary 
saprophytic  bacteria  of  the  intestinal 
contents,  and  not  specific  bacteria,  must 
be  held  responsible.  The  active  organ- 
isms cause  injury  to  the  intestinal  walls 
through  the  putrefactive  processes  of 
toxic  character  or  through  products  usu- 
ally non-toxic  in  character  (ammonia  and 
its  derivatives),  inasmuch  as  they  act  as 
inflammatory  irritants;  or  they  cause 
degeneration  of  the  vegetative  and  the 
most  important  excretory  organs  (liver, 
kidneys,  etc.)  through  the  blood-stream 
and  the  lymph-stream.  As  a  result  of 
the  interference  with  nutrition  and  the 
diminution  in  the  resistance  of  the  tis- 
sues thus  brought  about,  the  organism 
is  exposed  to  the  invasion  of  pathogenic 
bacteria  of  all  kinds  (staphylococci, 
streptococci,  pneumococci,  oidium  albi- 
cans, etc.).  There  also  results  a  predis- 
position to  disease,  as  manifested  by 
numerous  complications.  Baginsky  (Berl. 
klin.  Woch.,  Jan.  11,  '97). 

Study  of  thirteen  cases  leading  to  the 
following  conclusions: — 

1.  The  bacterium  coli  appears  to  be  the 
pathogenic  agent  of  the  greater  number 
of  summer  infantile  diarrhoeas. 

2.  This  organism  is  the  more  often 
associated  with  the  streptococcus  pyog- 
enes. 

3.  The  virulence,  more  considerable 
than  in  the  intestine  of  a  healthy  child, 
is  almost  always  in  direct  relation  to  the 
condition  of  the  child  at  the  time  the 
culture  is  taken,  and  does  not  appear  to 
be  proportional  to  the  ulterior  gravity 
of  the  case. 

4.  The  mobility  of  the  bacterium  coli 
is,  in  general,  proportional  to  its  viru- 
lence. The  jumping  movement,  never- 
theless, does  not  correspond  to  an  ex- 
alted virulence  in  comparison  with  the 
eases  in  which  the  mobility  was  very 
considerable  without  presenting  these 
jumping  movements. 

5.  The  virulence  of  the  bacterium  coli 
found  in  the  blood  and  other  organs  is 
identical  to  that  of  the  bacterium  coli 
taken  from  the  intestine  of  the  same  in- 
dividual. C.  G.  Cumston  (Inter.  Med. 
Jour.,  Mar.,  '97). 

The  toxic  symptoms  of  gastro-intes- 


tinal   infection   depend  upon  the  intro- 
duction  into    the   alimentary   canal    of 
poisonous    substances    which    are    con- 
tained in  the  food:    tj'rotoxicon,  for  in- 
stance, which  originates  in  milk,  and  is 
poisonous  for  man  and  animals.     Bac- 
teria may  be  introduced  from  without; 
or    the    ordinary    saprophytic    bacteria 
which  inhabit  the  intestinal  canal  may 
take  on   a  special  virulence.     But  the 
most    severe    disturbances    are    caused 
by  the  metabolism  of  bacteria;    these 
micro-organisms  by  their  activity  either 
produce  acids  or  cause  decomposition  of 
albuminoid    substances;     the    products 
act  as  powerful  irritants  to  the  intes- 
tines, and  by  injuring  the  intestinal  wall 
gain  access  to  the  blood  and  lymphatics, 
in  this  way  producing  the  local  and  con- 
stitutional  symptoms.     A.   Abt    (Medi- 
cine, Feb.,  1900). 
Pathology.  —  There     are     very     few 
changes  found  after  death  either  in  the 
intestinal  canal  or  in  any  of  the  organs. 
The  only  lesion  present  may  often  be  a 
desquamative  catarrh  of  the  gastro-in- 
testinal  tract.    In  those  cases  which  de- 
velop hydrencephalic  symptoms,  the  ap- 
pearances  found   after   death   bear   no 
proper  relation  to   the  gravity  of  the 
symptoms.     The  kidneys  are  generally 
found  paler  than  usual,  with  a  moderate 
cloudy  swelling  of  the  cortex,  but  not  to 
a  greater  extent  than  may  be  present  in 
other  febrile  disorders  of  infancy  (Holt). 
The   earlier  symptoms  may,   therefore, 
reasonably  be  ascribed  to  the  influence  of 
some  toxin  upon  the  heart,  nerve-centres, 
and  vasomotor  nerves  of  the  intestines, 
while  many  of  the  later  symptoms  must 
be  referred  to  the  great  abstraction  of 
serous  fluid  from  the  body. 

In  cholera  infantum  a  bacillus  found 
which  was  colored  after  the  method  of 
Gram.  Cultivated  in  gelatin  or  bouillon, 
an  alkaline  product  is  obtained,  having  a 
distinctive  odor,  which  it  retains  many 
months.  It  is  more  resistant  to  external 
agents  than  the  common  bacillus,  and 
more  tenacious  of  life.  Isolated,  it  is 
capable  of  producing  experimental  chol- 


CHOLERA  INFANTUM.     PROGNOSIS.    TREATMENT. 


159 


era,  like  several  other  microbes.  It  prob- 
ably plays  an  important  part  in  the  pro- 
duction of  cholera  infantum,  as  proved 
by  the  following  reasons:  1.  It  exists 
only  in  cases  of  cholera  infantum,  fre- 
quently in  large  numbers.  2.  It  produces 
experimental  cholera.  3.  It  produces  a 
substance  apparently  identical  with  that 
produced  by  the  comma  bacillus.  In 
doses  of  4  to  5  milligrammes  (%  to  Vio 
grain)  it  is  toxic,  and  causes  the  death 
of  the  animal.  4.  It  produces  choleraic 
intestinal  lesions.  Lesage  (La  Sem.  M6d., 
Apr.  9,  '90). 

In  spite  of  the  most  careful  researches, 
no  constant  micro-organism  has  been 
found,  the  comma  bacillus  not  being 
present.  At  times,  when  cholera  infan- 
tum is  prevalent  the  temperature  of  the 
child  is  often  considerably  above  normal, 
especially  toward  the  end  of  the  day.  It 
is  supposed  that  the  high  temperature 
indirectly  induces  some  changes  favor- 
able to  the  rapid  growth  of  saprophytic 
germs  already  present.  Alfred  H.  Carter 
(Provincial  Med.  Jour.,  July,  '93). 

Study   of  the   blood   of   three   cases. 
The  number  of  red  cells  is  diminished; 
the  total  number  of  white  cells  is  some- 
times augmented  and  sometimes  normal. 
The     lymphocytes     are     always     aug- 
mented;    the  mononuclears  always  di- 
minished;    the   polynuelears   and   poly- 
morphonuclears    are     sometimes     aug- 
mented   and    sometimes    normal.      The 
eosinophiles  are  absent  or  normal.    Nu- 
cleated red   cells   were   observed   twice. 
D'Orlandi    (Revue    Men.    des    Mai.    dc 
I'Enfance,  July,  '99). 
Prognosis. — Few  diseases  have  a  worse 
prognosis.     The  higher  the  rectal  tem- 
■peratiire,  the  younger  the  infant,  the  hot- 
ter the  weather,  and  the  more  unhygi- 
enic the  surroundings,  the  more  hopeless 
is  the  case.    Eotch  considers  the  disease 
to  be,  to  some  extent,  self-limited,  and 
thinks  that,  if  the  infant  survive  the 
first  three  daj's,  a  crisis  comes  and  the 
prognosis  improves. 

Prognosis  of  cholera  infantum  is  very 
unfavorable,  especially  when  the  child  is 
artificially  fed,  and  the  mortality  reaches 
very  commonly  95  or  97  per  cent.     In 


naturally-fed  children  the  death-rate  is 
low.  In  cases  where  the  brain  is  early 
affected,  with  coma  or  convulsions  pres- 
ent, the  prognosis  is  bad.  H.  N.  Potter 
(Annals  of  Gynec.  and  Ped.,  Apr.,  '98). 
Treatment.— Kegarding  the  disorder 
as  a  toxic  condition  due  to  the  absorption 
of  a  poison  from  the  alimentary  canal, 
our  first  efforts  must  be  directed  to  clear- 
ing out  this  tract  as  promptly  and  thor- 
oughly as  possible.  For  this  purpose  a 
few  grains  of  calomel  combined  with 
sodium  bicarbonate  should  be  given  in 
divided  doses.  As  soon  as  practicable, 
the  stomach  should  be  thoroughly 
washed  out  with  a  tepid  weak  solution 
of  sodium  bicarbonate  (V2  drachm  to  the 
pint).  Following  this  the  whole  tract 
of  the  colon  should  be  irrigated  with  a 
saline  solution  (1  drachm  of  sodium  chlo- 
ride to  the  pint).  To  insure  passage  of 
the  solution  into  the  higher  portions  of 
the  colon,  the  hips  of  the  infant  must  be 
well  elevated,  and  the  tube  passed  well 
up  into  the  bowel,  due  attention  being 
paid  to  its  curve.  The  solution  should 
be  allowed  to  run  into  the  gut  in  a  gentle 
steady  stream  from  a  fountain-syringe 
placed  at  a  height  not  exceeding  two  or 
three  feet.  Its  passage  upward  may  be 
favored  by  a  gentle  massage  along  the 
course  of  the  bowel.  The  temperature 
of  the  irrigating  fluid  (from  85°  F.  to 
105°  F.)  will  be  determined  by  the  con- 
dition of  the  patient  and  the  degree  of 
pyrexia. 

The  use  of  antiseptic  solutions  for  ir- 
rigating is,  in  our  opinion,  not  to  be 
recommended.  To  be  in  any  degree  ef- 
fectual they  must  have  a  moderate 
strength,  and  then  there  is  always  danger 
of  poisonous  absorption.  The  irrigations 
should  be  repeated  during  the  earlier 
hours  of  the  attack.  In  the  meantime, 
only  stimulants  and  ice  or  iced  water  in 
small  quantities  should  be  allowed  by 
the  mouth.     No  form  of  nourishment 


160 


CHOLERA  INFAis^TUM.    TREATMENT. 


should  be  permitted  during  the  first 
twentj'-four  hours.  The  digestive  func- 
tions of  the  stomach  and  duodenum  mast 
be  in  complete  abeyance,  and  any  food 
administered  -(vill  either  be  at  once  re- 
jected by  the  stomach,  increasing  its  hy- 
persemic  condition,  or,  if  retained,  will 
go  on  to  fermentation. 

No  food  of  any  kind  and  no  drugs 
given.  Boiled  water  at  the  ordinary  tem- 
perature, 3  V=  ounces  every  hour  for  at 
least  twenty-four  hours  and  hypodermic 
injections  of  1  Vi  to  6  drachms,  according 
to  age,  every  five  hours,  of  a  solution 
of:— 

IJ  Sterilized    (not    distilled)    water,    10 
ounces. 
Common  salt,  37  grains. 
Citrate   or   benzoate    of   caflfeine,    12 
grains. — M. 
These     injections     should     be     given 
slowly.     In  addition,  warm  baths    {95° 
F.)   twice  or  four  times  in  the  twenty- 
four  hours  should  be  given,  each  bath 
lasting  from  five  to  ten  minutes.    Wash- 
ing   out    the    stomach    and    intestines, 
though  useful  in  other  forms  of  infantile 
diarrhoea,  may  give  rise  in  choleraic  diar- 
rhoea to  convulsions  or  collapse.    In  con- 
valescence, if  the  diarrhoea  persists,  calo- 
mel or  subnitrate   of   bismuth   may   be 
given.    Not  any  satisfactory  results  ob- 
tained with  salol,  betol,  benzonaphthol, 
lactic  acid,   tannin,  or  opium.     Marfan 
(La  M6d.  Moderne,  June  lH,  '97). 
To  counteract  the  depressing  action 
of  the  poison,  and  to  prevent  the  paretic 
condition  of  the  intestinal  vasomotor  sys- 
tem, an  hypodermic  injection  of  mor- 
phine combined  with  atropine  is  probably 
our  best  remedy.    Holt  recommends  for 
an  infant  1  year  old  an  initial  dose  of 
not  more  than  '/loo  grain  of  morphine 
and  V«oo  grain  of  atropine.    This  may  be 
repeated  in  an  hour,  if  tlie  desired  sed- 
ative action  is  not  obtained. 

Infants  bear  atrojiine  wonderfully 
well.  Almost  adult  doses  of  atropine 
given  to  children  only  a  few  months  old; 
for  instance,  Vw  grain  of  morphine  and 
Vim  grain  of  atropine,  repeated  two  to 


four  times  in  twenty-four  hours.  This 
controls  the  phenomena  of  cholera  in- 
fantum, which  would  terminate  life  per- 
haps in  a  few  hours  without  such  treat- 
ment. William  Bailey  (Amer.  Pract. 
and  News,  July  1,  '93). 

There  is  no  drug  comparable  to  small 
doses  of  atropine  for  controlling  the  de- 
pression and  purging  of  cholera  infantum. 
Cecil  (Amer.  Pract.  and  News,  June  15, 
'98). 
Morphine,  it  should  be  remembered,  is 
contra-indicated  in  condition  of  drowsi- 
ness or  stupor.    Strychnine  hypodermic- 
ally  will  also  prove  of  some  service  as  a 
cardiac  and  respiratory  stimulant.    The 
effect  of  these  remedies  must  be  watched 
and  the  injections  repeated  as  may  be 
necessary  to  secure  the  desired  action. 
It  is  better  to  avoid  giving  powerful 
drugs  by  the  mouth,  as  doubt  must  exist 
as  to  the  rapidity  and  extent  of  their  ab- 
sorption. 

For  the  pyrexia  cool  baths  are  de- 
manded, and  should  be  administered  in 
all  cases  when  the  temperature  rises  over 
103°  F.  The  bath,  at  the  outset,  should 
have  a  temperature  of  97°  F.  and  should 
be  gradually  cooled  by  the  addition  of 
ice  or  iced  water  till  a  temperature  of  85° 
is  reached.  The  infant  should  remain 
in  the  bath  from  five  to  fifteen  minutes, 
according  to  the  effect  produced;  while 
in  the  bath  brisk  friction  should  be  em- 
ployed over  the  limbs  and  body  gener- 
ally. If  baths  are  impracticable,  the  cold 
wet  pack  may  be  employed.  An  ice-bag 
or  cold  cloths  should  be  kept  applied  to 
the  head. 

To  counteract  the  effects  of  the  drain 
of  fluid  from  the  tissues  no  method  can 
compare  with  the  injection  into  the  cel- 
lular tissue  of  a  sterilized  saline  solution 
(45  grains  of  sodium  chloride  to  the  pint 
of  water).  About '/,  pint  or  more  of  this 
solution  may  be  injected  at  once  into  the 
subcutaneous  tissue  of  the  thigh,  abdo- 
men, or  buttock;   the  injection  may  be 


CHOLERA  INFANTUM.     TREATilENX. 


161 


repeated  twice  a  day.  Marked  improve- 
ment in  all  the  symptoms  generally  fol- 
lows its  employment.  A  suitable  sy- 
ringe can  be  easily  made  by  attaching  an 
hypodermic  needle  to  the  nozzle  of  a 
Davidson  syringe  by  means  of  a  few 
inches  of  rubber  tubing. 

Saline  solutions  or  artificial  serum  suc- 
cessfully used.  The  physiological  salt  so- 
lution, which  seems  to  be  absorbed  most 
readily,  and  Hayem's  serum  preferred. 
The  most  practical  method  of  introduc- 
ing the  fluid  is  subcutaneously  into  the 
lumbar  or  gluteal  regions,  antiseptic  pre- 
cautions being  observed.  The  fluid  forma 
a  swelling  beneath  the  skin,  the  disap- 
pearance of  which  can  be  accelerated  by 
light  massage.  Marois  (Eevue  Men.  des 
Mai.  de  I'Enfance,  Dec,  '93). 

Hydrencephaloid  symptoms  call  for  a 
free  use  of  stimulants;  but  opium,  in 
this  condition,  is  better  avoided. 

During  the  course  of  the  disease  care 
must  be  given  to  insure  all  possible 
warmth  for  the  extremities.  Sinapisms 
over  the  stomach  may  be  of  occasional 
benefit. 

There  is  a  growing  tendency  on  the 
part  of  clinicians  to  consider  even  pure 
stiTilized  milk  as  a  source  of  danger, 
owing  to  the  properties  which  it  mani- 
fests as  a  culture-medium.  French  ob- 
servers are  especially  averse  to  its  use, 
particularly  in  the  acute  stage.  St. 
Philippe  states  that  its  suppression 
from  the  dietary  often  proves  curative. 
Meat-  and  vegetable-  broths  given  in 
small  doses  very  frequently  repeated 
are  kept  down  when  milk  will  at  once 
be  ejected.  White  of  egg  beaten  up  in 
cool  water  and  sweetened  with  sugar  of 
milk  to  precede  the  administration  of 
broths  recommended.  Sterile  water 
should  be  given  nd  libitum.  Fitch  (Med. 
Times,  Sept.,  1900). 

Method  of  treatment  adopted  by  Ba- 
ginsky,  who  insists  that  this  disease  re- 
quires ceaseless  observation  of  the  clin- 
ical manifestations.  The  great  and  im- 
mediate danger  is  from  the  loss  of 
fluids,  felt  specially  in  the  functionin'i 
of  the  organs  which  are  thus  stranded. 

2- 


as  it  were,  from  loss  of  their  accus- 
tomed medium.  The  body  may  lose 
one-tenth  to  one-fifth  of  its  weight  in 
the  diarrhoea  of  a  single  day  in  this  dis- 
ease. The  symptoms  observed  resem- 
ble in  many  respects  those  of  ureemia, 
and  are  due  to  the  lack  of  fluids  and 
the  consequent  retention  of  toxins  in 
the  body.  The  diarrhoea  carries  away 
much  of  the  causal  agents  and  this  may 
be  supplemented  by  calomel  and  castor 
oil.  A  mustard  bath  is  a  sovereign 
means  of  stimulating  the  vasomotors 
and  heart  from  the  periphery.  The  in- 
fant is  kept  in  the  bath  from  five  to 
eight  minutes — the  water  colored  a 
turbid,  yellowish  green  by  a  couple  of 
handfuls  of  mustard.  It  is  well  to  give 
the  mustard  bath  in  the  morning  in- 
stead of  the  ordinary  bath,  and  repeat 
it  during  the  day  If  needed,  carefully 
protecting  against  drafts  to  ward  off 
otitis  media.  Camphor  should  be  in- 
jected before  the  bath  and  again  every 
three  hours  in  urgent  cases  until  dan- 
ger of  collapse  is  past. 

Injections  of  artificial  serum  restore 
the  loss  of  fluid,  and  a  hypotonic  sa- 
line solution  should  be  preferred,  as  it 
is  more  rapidly  absorbed  and  as  salt  is 
more  or  less  contra-indicated  by  the 
nephritis  generally  present — a  half  a 
teaspoonful  of  salt  to  a  quart  of  boiled 
water.  The  amount  should  be  about 
20  to  30  c.  c.  per  kilogramme,  and  the 
injection  repeated,  if  necessary,  twice  a 
day.  It  is  supplemented  by  mineral 
waters.  The  practitioner  must  not  be 
misled  by  the  apparent  mildness  of  the 
attack  and  postpone  these  measures 
until  the  opportune  moment  has  passed. 
^\'llen  vomiting  continues,  notwith- 
standing abstention  from  food,  lavage 
of  the  stomach  is  called  for,  and  in 
many  cases  after  lavage  fiO  to  100  e.  c. 
of  the  above  salt  solution  is  pourol 
into  the  stomach  and  left  to  quiet  the 
tliir^t.  or  it  can  be  injected  into  the  rec- 
tum. .Mbumin  seems  to  bo  the  most 
harmful  food  in  cholera  infantum;  its 
nourishing  value  is  far  outweighed  by 
the  danger  from  its  putrefaction. 
Strict  asepsis  should  be  insured,  both 
for  the  infant  and  for  the  nurse,  in 
every  measure  undertaken.  Roeder 
(Thcr.  dcr  Gegen.,  vol.  xiv.  No.  6,  1904). 


162 


CHOLERA  MORBUS.  SVMPl'OMS. 


(See  also  Cholera  Morbus;  Infaxts, 
DiAKKHOSAL  DISORDERS  OF;   and  NURS- 
TSQ  AXD  Artificial  Feeding.) 
A.  D.  Blackader, 

Montreal. 

CHOLEEA  MOEBirS. 

Synonyms. — Cholera  nostras,  sporadic 
cholera,  summer  diarrhcea,  choleraic 
diarrhoea. 

Deinition. — An  acute  atlection  chiefly 
involving  the  stomach  and  intestines  and 
characterized  by  copious  diarrhoea  and 
vomiting,  first  of  the  ordinary  contents 
and  afterward  of  serous  fluid,  accom- 
panied by  abdominal  pains  and  rapidly- 
increasing  prostration.  It  was  recog- 
nized and  clinically  described  with  ac- 
curacy at  an  early  period  in  medical  his- 
tory, under  the  names  of  sporadic  and 
endemic  cholera.  It  frequently  occurs 
in  children  and  is  frequently  mistaken 
for  cholera  infantum  per  se,  now  re- 
garded by  pediatricians  as  a  separate 
disorder. 

Symptoms. — Cholera  morbus  is  liable 
to  occur  at  all  periods  of  life,  though 
much  more  frequently  during  infancy 
and  early  childhood  than  during  adult 
age.  For  convenience  of  clinical  descrip- 
tion, we  may  divide  the  cases  met  with  at 
the  bedside  into  two  groups.  In  those 
belonging  to  the  first  group  the  patient 
is  attacked  suddenly  with  copious  vomit- 
ing and  purging,  repeated  at  short  in- 
tervals. The  first  discharges  contain  the 
ordinary  contents  of  the  stomach  and 
bowels;  the  second  are  generally  stained 
with  the  coloring  matter  of  bile,  while 
the  subsequent  stools  consist  of  little  else 
than  large  quantities  of  simple  serous  or 
"rice-water"  fluid.  The  countenance 
soon  becomes  pale;  the  eyes  sunken;  the 
extremities  cold  and  shrunken;  the  pulse 
small,  frequent,  and  feeble;  the  urine 
scanty  and  sometimes  suppressed.    Fre- 


quent pains  in  the  abdomen  or  cramps 
in  the  muscles  of  the  extremities  cause 
paroxysms  of  great  sufl'ering.  The  mouth 
is  dry  and  the  thirst  sometimes  marked; 
the  voice  may  be  husky  or  feeble  and  the 
mind  dull  and  inactive. 

In  the  most  severe  cases  the  foregoing 
symptoms  develop  with  such  rapidity 
and  severity  that  a  fatal  collapse  is 
reached  in  less  than  twenty-four  hours. 
In  much  the  larger  number  of  cases, 
however,  after  the  first  few  hours  the 
discharges  become  less  frequent  and  pro- 
fuse; the  paroxysms  of  restlessness 
diminish;  the  pulse  is  less  frequent, 
and  at  the  end  of  twenty-four  hours  all 
the  more  active  symptoms  have  ceased, 
and  the  secretions  from  the  kidneys  and 
salivary  glands  have  returned  to  a  more 
natural  standard.  The  patient  remains 
pale,  languid,  and  weak  for  several 
days,  during  which  much  care  is  required 
in  the  regulation  of  diet,  drink,  and  ex- 
ercise to  avoid  a  relapse. 

In  the  second  group  of  cases  the  symp- 
toms commence  less  suddenly  and  are 
generally  more  persistent  in  duration. 
They  quite  uniformly  begin  with  diar- 
rhoeal  discharges,  soon  becoming  copious 
and  watery  or  semifluid,  frothy,  and 
sometimes  very  offensive,  with  free  vom- 
iting as  often  as  either  drinks  or  nourish- 
ment accumulate  in  the  stomach.  In 
from  four  to  six  days  the  patient  becomes 
so  much  exhausted  as  to  exhibit  all  the 
symptoms  of  approaching  collapse  de- 
scribed in  cases  of  the  first  group.  Ex- 
cept in  children  under  two  years  of  age, 
in  whom  there  may  be,  as  in  cholera 
infantum,  collapse  and  death  during  the 
first  or  second  week  of  their  progress, 
the  symptoms  dominate  in  intensity, 
about  the  end  of  the  first  week,  and  the 
vomiting  ceases  or  recurs  only  when  the 
stomach  is  allowed  to  become  too  full  of 
fluids.    The  intestinal  discharges  become 


CHOLEllA  MOKBUS.     DIFFERENTIAL  DIAGNOSIS. 


163 


less  frequent,  smaller  in  quantity,  and 
mixed  with  some  mucus  and  portions  of 
whatever  had  been  taken  for  nourish- 
ment. At  the  same  stage  of  progress  a 
moderate  grade  of  febrile  reaction  takes 
place,  causing  the  palms  of  the  hands 
and  surface  of  the  abdomen  to  become 
dry  and  warm;  the  tongue  and  mouth 
are  very  dry;  and  the  patient,  if  a  child, 
is  more  peevish  and  restless.  The  ap- 
pearance and  quality  of  the  intestinal 
discharges  vary  much  in  dilferent  cases, 
being  sometimes  like  turbid  water,  at 
other  times  green  or  light  yellow  with 
little  or  no  odor,  and  in  other  cases 
semifluid  and  very  offensive.  The  urine 
continues  scanty  and  sometimes  irritates 
the  urethra  in  passing;  the  emaciation 
continues,  and  in  many  young  children 
it  becomes  so  extreme  as  to  cause  death 
from  asthenia  in  from  one  to  three 
months.  But,  in  nearly  all  of  the  adults 
and  many  of  the  children,  after  the  dis- 
ease has  continued  from  one  to  four 
weeks  the  discharges  begin  to  improve 
both  in  quality  and  frequency,  digestion 
and  nutrition  increase,  and  in  a  few 
weeks  more  the  patients  have  regained 
a  fair  degree  of  health. 

Differential  Diagnosis. — The  diseases 
and  morbid  conditions  which  are  most 
likely  to  be  mistaken  for  cholera  morbus, 
both  in  children  and  adults,  are  epidemic 
cholera,  and  the  effects  of  direct  irri- 
tants, such  as  toxic  doses  of  arsenic, 
poisonous  mushrooms,  overripe  fruits, 
and  the  ptomaines  occasionally  in  ice- 
cream, cheese,  and  canned  meats,  and 
gastro-enteric  inflammation.  The  clinical 
phenomena  presented  by  severe  cases  of 
cholera  morbus  and  of  cholera  Asiatica 
are  so  nearly  identical  that  a  reliable 
diagnosis  cannot  be  founded  on  these 
phenomena  alone.  It  is  true  that  a  very 
large  proportion  of  the  cases  of  epidemic 
cholera  commence  with  painless,  watery 


diarrhceal  discharges  continuing  from 
one  to  three  or  more  days,  before  the 
violent  paroxysms  of  vomiting,  purging, 
and  cramps  begin.  When  cholera  mor- 
bus commences  with  diarrhcea  the  dis- 
charges are  accompanied  by  more  ordi- 
nary griping  or  abdominal  pains  and  the 
early  passages  are  more  mixed  with  the 
ingesta  and  appearances  of  bile.  In 
doubtful  cases  the  discovery  of  the 
cholera  bacillus  of  Koch  in  the  intes- 
tinal discharges  is  claimed  to  be  the 
only  reliable  proof  that  the  case  is  one 
of  true  epidemic  cholera.  But  there  is 
so  close  a  resemblance  between  the  com- 
mon bacillus  of  Koch  and  that  found  by 
Prior  and  Finkler  in  ihe  discharges  of 
ordinary  cholera  morbus  as  seen  under 
the  microscope,  that  cultures  are  re- 
quired to  complete  the  distinction  be- 
tween them.  Cases  of  sudden  and  severe 
vomiting  and  purging  caused  by  irri- 
tating ingesta  are  more  readily  distin- 
guished from  cholera  morbus  by  their 
commencing  very  soon  after  the  taking 
of  bad  food  or  poisonous  substances, 
and  by  the  existence  of  more  constant 
burning  sensations  or  distress  at  the 
epigastrium.  The  discharges  also  early 
show  intermixture  of  mucus  and  some- 
times streaks  of  blood,  which,  in  cholera 
morbus,  seldom  appear  until  in  the  ad- 
vanced stage  of  the  disease.  In  gastro- 
enteritis the  gastric  and  intestinal  dis- 
charges are,  from  the  beginning,  less 
copious  and  are  mixed  with  mucus; 
there  is  more  epigastric  distress,  more 
febrile  heat,  and  more  frequent  efforts 
to  vomit,  with  the  ejection  oi  only  small 
quantities  of  mucus  of  a  green  or  yellow 
color. 

In  the  advanced  stage  of  some  of  the 
more  severe  cases  of  cholera  morbus  a 
condition  of  morbid  vigilance,  with  roll- 
ing of  the  head,  tossing  of  the  hands, 
and  moaning,  supervened  and  sometimes 


164 


CHOLERA  MORBUS.    iiXIOLOGY. 


ended  in  a  general  convulsion.  These 
symptoms  have  generally  caused  the 
friends,  and  sometimes  the  attending 
physician,  to  think  that  disease  was  de- 
veloping in  the  brain.  I  have  seen  a 
few  of  such  cases  treated  with  cold 
applications  to  the  head  and  blisters  be- 
hind the  ears,  while  the  real  cause  of 
the  symptoms  was  cerebral  anaemia  or 
exliaustion. 

Microscopical  examinations  have 
shown  the  presence  of  a  variety  of 
micro-organisms  in  the  discharges  of 
cholera  morbus,  but  no  one  of  them  has 
yet  proved  to  be  of  diagnostic  value. 

Etiology. — Abundant  clinical  observa- 
tions and  vital  statistics  have  shown  that 
cholera  morbus,  both  in  children  and  in 
adults,  prevails  most  in  those  parts  of 
the  temperate  zone  characterized  by  a 
wide  range  of  temperature  between  the 
coldest  days  of  winter  and  the  hottest 
days  of  summer.  Its  prevalence  is  lim- 
ited almost  wholly  to  the  months  of 
June,  July,  August,  and  September,  gen- 
erally commencing  with  the  first  pros- 
trated wave  of  high  temperature  during 
the  last  week  in  June  or  the  first  in 
July  and  reaching  its  greatest  prevalence 
by  the  middle  of  the  latter  month.  Thus, 
of  the  1119  deaths  from  cholera  morbus 
and  cholera  infantum  in  Chicago  in 
1896,  1  was  reported  in  January,  2  in 
April,  8  in  May,  180  in  June,  485  in 
July,  339  in  August,  108  in  September, 
1  in  October,  and  1  in  December.  In 
1895  the  whole  number  of  deaths  from 
the  same  disease  was  1345,  of  which  6 
were  reported  in  March,  3  in  May,  187 
in  June,  554  in  July,  315  in  August, 
275  in  September,  2  in  October,  2  in 
November,  and  1  in  December.  So  great 
a  mortality  occurring  regularly  during 
the  hottest  months  of  each  year  induced 
me  to  make  the  subject  a  special  study 
during  the  decade  following  1870.    The 


facts  gathered  by  such  study  justified  the 
conclusion  that  cholera  morbus,  in  both 
adults  and  children,  commences  uni- 
formly during  the  first  period  of  high 
summer  temperature  continuing  day 
and  night  not  less  than  five  days  con- 
secutively, and  new  cases  appear  during 
each  similar  hot  period  for  sixty  of 
ninety  days.  It  is  not  simply  high  tem- 
perature for  a  single  day,  or  for  three  or 
four  days  while  the  nights  remain  cool, 
but  high  temperature  both  day  and 
night,  four  or  five  days  in  succession, 
that  favors  the  development  of  the  dis- 
ease. If  the  air  is  stagnant  from  absence 
of  wind,  or  overcrowding  and  narrow 
streets,  as  in  populous  cities,  the  number 
of  attacks  will  be  much  increased.  On 
the  other  hand,  cities  and  towns  so 
located  that  the  nights  are  favored  by 
cooler  breezes  from  the  sea  suffer  but 
little  from  ordinary  choleraic  attacks. 

Nearly  all  the  writers  on  general  prac- 
tice and  on  diseases  of  children  mention 
high  temperature  and  overcrowded  and 
poorly  ventilated  dwellings  as  merely 
predisposing  causes  of  the  disease  under 
consideration;  while  they  enumerate,  as 
direct  exciting  causes,  the  taking  of  im- 
proper food,  as  mixed  salads,  impure  or 
changed  milk,  impure  and  confined  air, 
and,  in  infants,  the  progress  of  denti- 
tion and  the  nursing  of  overworked, 
improperly  fed,  and  unhealthy  mothers 
or  nurses. 

That  all  these  causes  exist  and  occa- 
sionally directly  excite  attacks  of  cholera 
morbus  in  both  children  and  adults  there 
can  be  no  doubt.  But  as  they  all  exist 
in  all  large  cities  and  populous  districts, 
and  at  all  seasons  of  the  year,  if  they 
were  the  chief  causes  of  the  disease  it 
should  prevail  at  all  seasons  of  the  year 
instead  of  being  confined  to  three  or  four 
of  the  hottest  months,  and  it  should  pre- 
vail as  much  in  cities  so  located  as  to 


CHOLERA  MORBUS.     PATHOLOGY.     PROGNOSIS. 


165 


receive  cool  breezes  during  the  summer 
nights  as  in  those  that  do  not.  There  is. 
probably  as  much  lack  of  ventilation 
and  as  much  use  of  poor  or  adulterated 
milk  and  other  articles  of  food  during 
the  winter  as  during  the  summer.  And 
there  are  quite  as  many  overworked  and 
badly-fed  mothers,  and  as  many  infants 
"cutting  teeth,"  in  the  month  of  Janu- 
ary as  in  July,  yet,  as  stated  above,  dur- 
ing the  years  1895  and  1896  in  Chicago 
only  1  death  was  reported  from  cholera 
morbus  and  infantum  in  January  and 
1039  in  July.  Such  results  show  un- 
mistakably that  high  temperature,  con- 
tinued through  several  consecutive  days 
and  nights,  constitutes  the  ruling  factor 
in  the  causation  of  the  disease  under 
consideration.  The  higher  the  tempera- 
ture of  the  atmosphere,  the  less  amount 
of  oxygen  is  contained  in  each  cubic  foot, 
and  consequently  less  reaches  the  air- 
cells  of  the  lungs  at  each  breath  and 
less  is  distributed  to  the  tissues  of  the 
body  in  a  given  time.  Hence  the  nerv- 
ous and  muscular  structures  become  re- 
laxed, the  watery  elements  of  the  blood 
escape,  the  perspiration  carrying  with  it 
the  free  salts  of  the  blood,  w^hich  still 
further  diminishes  its  capacity  for  taking 
up  oxygen  from  the  air-cells  of  the  lungs. 
If  this  condition  of  things  is  continued 
through  several  successive  days  and 
nights,  the  capillaries  of  the  mucous 
membranes  of  the  stomach  and  intes- 
tines relax,  and  allow  the  serous  element 
of  the  blood  to  escape  more  freely  than 
perspiration  from  the  cutaneous  sur- 
faces, and  choleraic  discharges  more  or 
less  profuse  are  the  result.  If  the 
patient  is  confined  in  a  close,  ill-ven- 
tilated room,  as  is  likely  to  be  the  case 
with  young  cliildren,  especially  at  night, 
the  evil  efFects  are  much  increased.  And 
close  investigation  shows  that  the  begin- 
ning of  a  large  majority  of  the  cases 


occurs  during  the  last  half  of  the  night 
or  early  in  the  morning. 

Since  the  etiological  study  of  patho- 
logical bacteria  with  their  ptomaines 
and  toxins  has  come  to  engross  the  at- 
tention of  the  profession,  and  especially 
since  the  discovery  of  the  epidemic 
cholera  bacillus  by  Koch,  many  writers 
have  suggested  that  cholera  morbus  also 
depended  for  its  essential  cause  on  a 
specific  bacillus  or  its  toxins.  But  no 
such  organism  has  as  yet  been  identified 
as  the  essential  cause. 

Pathology. — The  essential  pathological 
conditions  involved  in  cases  of  uncom- 
plicated cholera  morbus  are  a  morbidly 
sensitive  condition  of  the  mucous  mem- 
brane of  the  alimentary  canal,  a  general 
impairment  of  the  tonicity  of  tissues 
with  deficient  oxygenation  of  the  blood, 
and  so  decided  an  impairment  of  the 
vasomotor  nervous  influence  over  the 
vessels  of  the  mucous  membranes  of  the 
stomach  and  intestines  as  to  allow  copi- 
ous exudation  of  the  serous  elements  of 
the  blood.  The  exudation  constituting 
the  cholera  discharges  results  from  these 
conditions  and  has  no  necessary  connec- 
tion with  any  grade  of  inflammation, 
catarrhal  or  otherwise.  This  is  proved 
by  the  fact  that,  in  the  most  rapidly  fatal 
cases,  post-mortem  examinations  re- 
vealed no  ordinary  traces  of  inflamma- 
tion in  the  mucous  membranes.  It  is 
only  in  the  cases  that  run  a  more  pro- 
tracted course  in  which  febrile  reaction 
occurs,  followed  by  more  or  less  mucous 
discharges,  that  we  find  appearances  of 
ordinary  catarrhal  inflammation. 

Prognosis.  —  Cholera  morbus,  as  it 
occurs  in  adults  and  in  children  over  five 
years  of  age,  runs  a  brief  course  and  gen- 
erally ends  in  recovery.  Only  a  small 
percentage  of  such  cases  terminate 
fatally.  It  is  very  different,  however, 
when  the  disease  attacks  infants  or  chil- 


166 


CHOLERA  MORBUS.    TREATMENT. 


dren  under  three  years  of  age.  Only  a 
small  percentage  of  this  mortality  re- 
sults from  the  violence  of  the  first  stage 
and  direct  collapse.  Much  the  larger 
part  results  from  the  occurrence  of  re- 
action and  the  establishment  of  a  per- 
sistent grade  enteritis  and  progressive 
exhaustion  and  emaciation. 

Treatment. — In  the  beginning  of  at- 
tacks of  active  cholera  morbus  the  lead- 
ing objects  to  be  gained  by  treatment  are 
to  allay  the  morbid  sensitiveness  of  the 
mucous  membrane  of  the  alimentary 
canal;  to  restore  the  general  tonicity  of 
the  tissues  and  of  the  vasomotor  nervous 
system;  to  promote  the  natural  secre- 
tions, especially  of  the  liver  and  kidneys; 
and  to  properly  regulate  the  diet,  drinks, 
and  general  sanitary  surroundings  of  the 
patient.  In  the  treatment  of  all  this 
class  of  patients  it  is  of  the  greatest  im- 
portance to  secure  for  them  a  constant 
supply  of  fresh,  pure  air.  The  most 
complete  ventilation  possible  and  rigid 
cleanliness  should  be  enforced  day  and 
night.  To  accomplish  this  is  often  a 
very  difficult  task  among  all  the  classes 
of  people  who  occupy  small  or  over- 
crowded lodging-rooms  on  the  narrower 
and  less-cleanly  streets  of  our  large 
cities.  But  a  firm  insistance  upon  keep- 
ing whatever  doors  and  windows  there 
are  freely  open  during  hot  summer 
nights  as  well  as  during  the  day,  and  the 
prompt  removal  of  all  gastric  and  in- 
testinal discharges  from  the  room,  will 
accomplish  much  in  this  direction.  To 
overcome  the  morbid  sensitiveness  of 
the  mucous  membrane,  restore  the  tonic- 
ity of  the  nervous  and  vascular  systems, 
and  increase  natural  secretions,  we  need 
the  combined  or  coincident  use  of  ano- 
dyno.B,  antiseptics,  and  tonics.  In  the 
early  stage  of  active  vomiting  and  diar- 
rhoea the  following  formula  has  been 
used  with  the  most  satisfactory  results: — 


I^  Carbolic  acid,  T^/^  grains. 
Glycerin,  5  drachms. 
Camphorated  tincture  of  opium,  2 

ounces. 
Cinnamon-water,  2'/^  ounces. — ^M. 

To  an  adult  one  teaspoonful  of  this 
mixture  is  to  be  given  immediately  after 
each  paroxysm  of  vomiting  until  the 
parox^'sms  cease  to  recur.  Vomiting  is 
never  a  continuous  process,  and  if  a  dose 
of  medicine  is  given  as  soon  as  possible 
after  a  paroxysm  a  few  minutes  will 
elapse  before  the  patient  can  vomit,  and 
thus  some  impression  of  the  medicine  is 
obtained.  But  if  we  follow  the  inclina- 
tion of  the  patients  and  nurses  and  wait 
for  the  patient  to  "rest  a  little"  and  the 
stomach  to  become  "settled,"  we  simply 
allow  time  enough  for  the  stomach  to 
regain  ability  to  vomit  with  another 
supply  of  serous  exudation,  and  now  the 
dose  of  medicine  is  likely  to  be  ejected 
as  soon  as  swallowed.  The  teaspoonful 
of  the  mixture  may  be  given  in  half  a 
tablespoonful  of  water;  and  in  treating 
young  children  the  dose  should  be  ap- 
portioned to  the  age  of  the  child.  In 
addition  to  the  above,  small  doses  of 
calomel  may  be  given  every  half-hour  or 
hour  until  the  discharges  become  less 
watery  and  show  some  indications  of  the 
presence  of  bile.  Sinapisms  of  mustard 
may  be  applied  over  the  epigastrium  and 
to  the  back  over  the  spine,  but  should 
be  allowed  to  remain  only  long  enough 
to  redden  the  skin  without  vesicating  it. 

As  soon  as  vomiting  has  ceased  and 
the  intestinal  discharges  show  evidence 
of  hepatic  secretion,  it  is  generally  only 
necessary  to  continue  the  formula  recom- 
mended every  two,  three,  or  four  hours 
until  the  diarrhoea  also  has  ceased  and 
the  patient  is  inclined  to  sleep.  In  many 
cases  no  further  use  of  the  preparation 
is  required,  rest  and  a  judicious  regula- 


CHOLKRA  MORBUS. 


CHOLURIA. 


167 


tion  of  the  diet  for  a  few  days  being  suf- 
ficient to  restore  the  patient  to  health. 

Sometimes,  however,  the  patient's 
mouth  remains  dry,  the  pulse  more  fre- 
quent than  natural,  the  palms  of  the 
hands  and  the  surface  of  the  abdomen 
warmer  than  natural,  the  urine  scanty, 
and  several  diarrheal  discharges  each 
day  accompanied  by  pain  and  restless- 
ness. In  such  cases  a  continuance  of  the 
carbolic-acid  formula,  already  given, 
with  a  few  drops  of  nitrous  ether  added 
to  each  dose,  and  giving,  for  nourish- 
ment only,  a  thin  gruel  or  porridge  made 
of  good  milk  and  wheat-flour,  or  pure 
milk  with  a  little  fresh  lime-water  added, 
will  often  insure  recovery. 

A  very  great  variety  of  other  reme- 
dies have  been  used  with  more  or  less 
benefit,  nearly  all  of  them,  however, 
combining  anodyne,  antiseptic,  and 
astringent  or  tonic  properties  with  strict 
regulations  of  diet.  The  use  of  potas- 
sium bromide  in  the  cholera  morbus  of 
infants  has  recently  been  strongly  rec- 
ommended by  M.  L.  Brown.  Prepara- 
tions of  bismuth,  generally  given  with 
small  doses  of  codeine  or  other  anodyne, 
have  long  been  used  with  benefit  in  the 
protracted  cases.  In  treating  cases,  espe- 
cially in  young  children,  much  care 
should  be  exercised  in  giving  opiates 
and  astringents,  lest  they  add  to  the 
tardiness  of  the  kidneys  in  secreting 
urine,  and  thereby  increase  the  danger 
of  coma  or  convulsions.  (See  Cholera 
Infantum  and  Infantile  Diarrhcea.) 
Nathan  S.  Davis, 

Cliicago. 

CHOLERA  NOSTRAS.    See  Cholera 

AsiATKw  and  Cholera  JIorbus. 

CHOLTJRIA. 

Definition. — Choluria  is  a  morbid  con- 
dition of  the  urine  observed  in  jaundice 
and  characterized  by  the  presence  in  it 


of  the  constituents  of  the  gall,  especially 
the  bile-pigments  and  the  bile-acids. 

In  urobilinuria  the  normal  constitu- 
ents of  the  bile  are  not  found  in  the 
urine,  but  a  derivative  of  the  bile-pig- 
ments— the  urobilin — is  found  instead. 

Symptoms. — Although  the  bile-acids 
are  ordinarily  present  in  the  urine  in 
choluria,  they  do  not  occasion  character- 
istic symptoms,  and  can  only  be  revealed 
by  special  tests.  The  presence  of  the 
bile  is  more  easily  detected. 

The  urine  containing  bilirubin  exhib- 
its a  color  varying  from  a  light  saflron- 
yellow  to  one  resembling  mahogany  or 
porter;  even  when  the  color  is  dark 
brown  or  almost  black  the  urine  will 
show  a  tinge  of  olive-green  or  green- 
brown  when  it  is  seen  in  thin  strata.  The 
color  of  the  urine  may  resemble  that  of 
a  very  concentrated  urine  or  of  urine  con- 
taining blood;  in  the  later  cases  the  froth 
of  the  urine  is  white,  while  the  froth  of 
the  icteric  urine  is  yellow  and  tinges 
white  a  piece  of  linen  or  blntting-paper 
dipped  into  it. 

On  standing,  icteric  urine  ordinarily 
becomes  greenish,  because  the  bilirubin, 
by  oxidizing,  changes  into  biliverdin;  by 
further  decomposition  of  the  urine  the 
pigments  are  further  changed  into  bili- 
prasin  and  bilifuscin. 

Although  cholesterin  is  a  normal  con- 
stituent of  the  bile,  it  is  not  found  in  the 
urine  in  choluria,  but  in  other  morbid 
conditions  of  the  urine:  e.(j.,  chyluria. 

In   some   cases   of  cholurin   renal   cast 
observed   in   the   urine   without  albumi- 
nuria.   Nothnagcl  (Deut.  Archiv  f.  klin. 
Med.,  xiii,  p.  487). 
Diagnosis.  —  Different  remedies  may 
give  the  urine  a  color  resembling  that 
observed  in  choluria.     Wlien  santonin. 
thallin,  rhubarb,  or  picric  acid  have  been 
ingested,  the  urine  and  its  froth  will  pre- 
sent a  yellow  color.    In  poisoning  with 
the  fruit  of  Ci/tissus  lahiimum  a  dark- 


168 


CHOLURIA.     TESTS. 


green  color  of  the  urine  is  observed, 
whereas  it  is  blue-green  after  the  inges- 
tion of  methylene-blue.  The  presence  of 
the  bile-pigments  are  revealed  by  differ- 
ent tests. 

1.  Gvielin's  test  consists  "in  bringing 
strong  nitric  acid  containing  some  ni- 
trous acid  in  contact  with  the  urine;  if 
bile  be  present,  a  play  of  color  is  devel- 
oped from  green  to  blue,  violet,  and 
finally  red.  These  changes  are  due  to 
the  gradual  oxidation  of  the  bile-pig- 
ments. The  green  color  is  the  most  char- 
acteristic, being  dependent  on  the  forma- 
tion of  biliverdin.  It  must  be  remem- 
bered that  in  most  urines  a  reddish  tint 
is  brought  out  by  nitric  acid,  while,  if 
much  indican  is  present,  a  blue  or  violet 
color  may  be  developed. 

Gmelin's  test  is  best  performed  by 
pouring  a  few  cubic  centimetres  of  nitric 
acid  in  a  test-tube  or  a  conical  glass;  the 
urine  is  then  allowed  to  flow  gently  so  as 
to  cause  it  to  fall  on  the  surface  of  the 
acid.  The  play  of  color  is  then  observed 
at  the  junction  of  the  liquids.  The  urine 
may  also  be  placed  in  the  tube  first  and 
the  acid  poured  in  gradually  so  that  it 
sinks  down  to  the  bottom.  Only  the 
green  color  is  evidence  for  the  presence 
of  bile-pigment,  since  the  other  colors 
may  be  due  to  the  action  of  the  acid 
upon  the  normal  urine-pigments.  The 
presence  of  albumin  is  of  no  consequence; 
the  green  color  is  even  more  visible 
against  the  white  albuminous  deposit. 
Gmelin's  test  has  been  modified  in  dif- 
ferent ways. 

Rosenbaeh  proposes  to  filter  the  urine 
through  white  blotting-paper  and  place 
a  drop  of  nitric  acid  on  the  filter  while 
still  moist;  or  a  drop  of  the  urine  and  of 
the  acid  are  placed  separately  on  a  white 
porcelain  surface  and  allowed  to  come  in 
contact.  In  both  cases  the  characteristic 
color-rings  will  appear. 


Gmelin's  test  is  very  reliable  when  the 
quantity  of  bile-pigments  is  not  too 
small;  when  this  is  the  case,  however,  it 
is  necessary  to  isolate  the  pigment  by 
gently  shaldng  the  urine  with  chloro- 
form; this  agent  will  dissolve  the  bili- 
rubin and  cause  a  yellow  color.  When 
the  test-tube  is  left  quiet  for  some  min- 
utes the  chloroform  solution  of  bilirubin 
will  sink  to  the  bottom,  the  urine  can 
be  poured  out,  and  the  test  performed 
■fl-ith  the  chloroform  solution.  Indican 
is  not  dissolved  by  chloroform. 

Different  oxidizing  substances  have 
been  used  instead  of  nitric  acid. 

2.  The  iodine  test  (Smith-Marechal) : 
^Mien  a  few  drops  of  tincture  of  iodine 
are  added  to  urine  containing  bile-pig- 
ment an  emerald-green  color  will  appear. 
A  watery  solution  of  bromine  will  pro- 
duce a  similar  effect. 

3.  Huppert's  test :  A  solution  of  am- 
monia and  chloride  of  calcium  is  added 
to  the  urine.  When  bilirubin  is  present 
a  deposit  of  bilirubin-chalk  will  be 
formed,  which  is  filtered  and  washed 
down  in  a  test-tube  together  with  strong 
alcohol  containing  sulphuric  acid.  When 
boiled  the  liquid  takes  a  blue-green  or 
emerald-green  color. 

4.  Jolles  recommends  the  following 
method:  To  50  cubic  centimetres  of 
urine,  a  drop  of  hydrochloric  acid,  chlo- 
ride of  barium  in  excess,  and  5  cubic 
centimetres  of  chloroform  are  added. 
The  mixture  is  shaken  and  left  standing 
for  10  minutes,  then  poured  out  and  the 
chloroform  heated  in  a  water-bath;  3 
drops  of  sulphuretted  sulphuric  acid  con- 
taining one-fourth  of  its  volume  of  fum- 
ing sulphuric  acid  are  added.  The  char- 
acteristic rings  are  found  at  the  bottom 
of  the  tube. 

!).  When  only  bilirubin  is  to  be  re- 
vealed the  sulpho-diazo-benzol  test  of 
Ehrlich  may  be  of  use.    The  reagent  and 


CHOLURIA.     ETIOLOGY  AND  PATHOLOGY. 


169 


diluted  acetic  acid  are  added  to  the  urine. 

When  the  mixture  becomes  dark,  a  few 

drops  of  glacial  acetic  acid  will  bring  out 

the  characteristic  violet  color. 

Modification  of  Ehrlich's  test:  Three 
reagents  are  employed:  (1)  a  1-per-cent. 
watery  solution  of  sulphanilic  acid,  (2) 
a  l-per-cent.  watery  solution  of  nitrite 
of  soda,  and  (3)  pure  concentrated  hy- 
drochloric acid. 

In  a  test-tube  a  few  drops  of  the  first 
and  second  agents  are  mixed  with  as 
much  urine;  a  drop  of  hydrochloric  acid 
is  added  and  the  mixture  shaken.  It  will 
then,  when  bilirubin,  even  if  a  very  small 
amount,  is  present,  get  dark  violet.  ^Vhen 
the  liquid  is  mi.xed  with  water  the  color 
changes  into  amethyst-violet.  When 
only  a  very  small  quantity  of  bilirubin 
is  present,  the  violet  color  will  appear 
after  a  few  minutes. 

This  test  regarded  as  the  most  reliable 
and  delicate  of  all.  Krokiewicz  and 
Batko  (Wiener  med.  Woch.,  Feb.  24,  '98). 

The  biliary  pigments  in  the  urine  may 
decompose  by  standing,  and  then  the 
above-mentioned  tests  will  be  without  re- 
sult. Bilifuscin,  which  is  formed  by  de- 
composition of  the  bilirubin,  is  revealed 
by  moistening  white  blotting-paper  with 
the  urine;  the  paper  will  assume  a  brown 
color. 

Urobilin  is  dissolved  by  chloroform, 
and  the  solution  takes  a  greenish  fluores- 
cent color  upon  the  addition  of  iodine 
and  caustic  potash.  Von  Jaksch  recom- 
mends the  test  of  Iluppert:  when  urob- 
ilin is  present  the  deposit  is  red-brown 
and  becomes  brown  or  gray-brown  by 
boiling  ^vith  sulphuric  acid. 

Pettenliofer's  test:  The  bile-acids  are 
detected  by  means  of  this  test,  which  de- 
pends on  the  development  of  a  deep- 
purple  color  when  these  acids  are  acted 
upon  by  cane-sugar  and  strong  sulphuric 
acid.  This  reaction  is,  however,  for  sev- 
eral reasons,  most  unreliable  when  ap- 
plied to  urine,  and  the  bile-acids  must 
be  separated  from  the  urine  by  a  compli- 


cated method  before  the  original  Petten- 
kofer  test  can  be  made. 

Strassburger,  therefore,  has  modified 
the  test  in  the  following  manner:  Cane- 
sugar  is  added  to  the  urine,  and  the  solu- 
tion is  filtered  through  white  filtering- 
paper.  After  drj'ing  the  filter  a  drop  of 
strong  sulphuric  acid  is  placed  upon  it, 
and  after  one-half  minute  a  beautiful-red 
color  will  appear  if  bile-acid  be  present; 
the  color  finally  changes  into  a  dark 
purple. 

Physiological  test  for  bile  in  the  urine 
depending  upon  the  fact  that  the  bile- 
salts  precipitate  the  peptones  from  solu- 
tion. The  precipitate  produced  by  urine 
containing  bile-salts  in  a  peptone  solu- 
tion acidulated  with  acetic  acid  is  soluble 
in  acetic  or  citric  acid,  thus  differing 
from  all  other  precipitates  in  the  urine 
produced  by  acidulated  reagents.  Fur- 
ther, the  precipitate  may  only  be  par- 
tially cleared  up  by  heat.  Quantitative 
application  of  the  same  principle  may 
also  be  made.  George  Oliver  ("Bedside 
Urine-testing,"  '89). 

Etiology  and  Pathology.  —  Choluria 
takes  place  when  the  constituents  of  the 
bile  are  absorbed  by  the  lymphatics  and 
pass  into  the  blood-vessels,  from  where 
they  are  excreted  by  the  kidneys.  It  is, 
therefore,  a  constant  symptom  of  jaun- 
dice, and  is  often  observed  before  either 
the  skin  or  the  mucous  membranes  get 
stained  with  bile-pigment.  The  condi- 
tions which  give  rise  to  icterus  will  be 
discussed  elsewhere,  but  by  the  examina- 
tion of  the  urine  it  will  never  be  possible 
to  discover  the  origin  of  the  jaundice. 
In  some  cases  the  pigment  contained  in 
the  urine  does  not  seem  to  be  due  to 
absorption  of  bile  in  the  liver,  but  to 
have  been  formed  directly  by  decomposi- 
tion of  the  blood-pigments,  either  while 
circulating  in  the  blood  (ha^matogen  ic- 
terus) or  after  the  blood  has  been  ex- 
travasated  in  the  tissues  (Quincke's  in- 
ogen  icterus). 


170 


CHOLURIA. 


Prognosis  aad  Treatment. — As  cho- 
Imia  is  only  a  symptom  of  absorption  of 
bUe  by  the  blood,  its  prognosis  is  in  close 
relation  to  that  of  the  disease  acting  as 
cause.  Even  if  the  choluria  is  very  con- 
siderable, it  will  quickly  disappear  when 
the  obstacles  for  the  regular  flow  of  the 
bile  are  removed.  The  treatment  must 
also  be  directed  against  the  fundamental 
disease,  while  the  symptom,  choluria, 
needs  no  special  treatment. 

F.  Levisok, 

Copenhagen. 

CHORDEE.  See  Ukinart  System, 
SuEGiCAL  Diseases  of;  Gonoerhcea. 

CHOEDITIS  VOCALIS.  See  Laryn- 
gitis. 

CHOREA. — From  the  Greek:    j^opeia. 

Synonym. — St.  Vitus's  dance. 

Some  confusion  arises  from  the  fact 
that  under  the  name  "chorea"  are. in- 
cluded several  forms  of  nervous  disease 
and  degeneracy  having  as  their  com- 
mon and  characteristic  symptom  jerky, 
arhythmic,  involuntary,  inco-ordinate, 
muscular  movements,  while  differing 
widely  from  one  another  in  nature,  causa- 
tion, pathology,  prognosis,  and  general 
symptomatology.  This  confusion  is 
further  added  to  by  the  varying  opinions 
held  by  those  who  write  upon  the  sub- 
ject as  to  what  conditions  shall  and  what 
shall  not  be  included  among  the  choreas. 

The  following  forms  are  described: — 

1.  Sydenham's  chorea.  With  several 
varieties,  as  "chorea  insaniens,"  "hemi- 
chorea,"  etc. 

2.  Endemic  chorea. 

3.  Electric  chorea. 

4.  Hysterical  chorea. 

5.  Saltatory  spasm. 

6.  Oscillatory  spasm. 

7.  Tic  co-ordinc,  or  "habit  spasm." 

8.  Post-hemiplcgic  chorea. 


9.  Chronic  adult  chorea. 

10.  Huntington's  chorea. 

Of  these,  the  first  in  order  is  the  com- 
mon St.  Vitus's  dance,  chorea  minor,  or 
acute  curable  chorea,  and  much  the  most 
common  and  important  of  the  choreoid 
diseases.  It  is  the  form  meant  when  the 
word  chorea  is  used  without  qualifica- 
tion. Those  included  from  the  second 
to  the  seventh  belong  to  the  functional 
neuroses,  and  may  be  regarded  as  ex- 
pressions of  neurodegeneracy.  The 
eighth,  ninth,  and  tenth  are  attended  by 
degenerative  changes  in  the  cortex  cere- 
bri or  spinal  cord,  or  both. 

Sydenham's  Chorea. 

Definition. — This  is  the  well-known 
"St.  Vitus's  dance,"  an  acquired  func- 
tional neurosis,  occurring  during  the 
middle  and  later  periods  of  childhood, 
being  rarely  seen  before  the  age  of  five 
years  and  after  puberty;  it  is  more  com- 
mon in  females  than  in  males,  is  more 
frequently  met  with  in  urban  than  in 
rural  populations,  and  during  the  spring 
months. 

Symptoms. — The  onset  of  the  disease 
is  often  foreshadowed  by  symptoms  cov- 
ering a  prodromal  period  of  a  few  days 
to  a  few  weeks.  These  premonitory 
symptoms  consist  in  general  nervousness, 
a  tendency  to  fidget  and  uneasiness,  a 
change  in  disposition;  irritability  and 
emotional  weakness,  headache,  vague 
pains,  some  impairment  of  general 
health,  and  possibly  the  occurrence  of 
some  one  of  the  acute  diseases  or  unfav- 
orable circumstances  enumerated  below 
as  exciting  causes  of  the  disorder.  The 
disease  always  develops  gradually  and 
with  varying  rapidity  in  dilTcrent  cases, 
the  onset  being  marked  by  the  appear- 
ance of  the  characteristic  choreic  move- 
ments. These  are  peculiar,  jerky,  often 
lightning-like,  clonic  spasms,  involving 
the  muscles  of  the  face  and  head,  neck, 


CHOREA.     SYMPTOMS. 


171 


trunk,  and  extremities,  usually  more  pro- 
nounced in  the  face  and  arms,  and  often 
more  pronounced  in  one  lateral  half  of 
the  body  ("liemichorea,"  when  typically 
shown).  The  movements  are  sudden  in 
onset  and  as  suddenly  cease;  they  are 
irregxilar  in  force  and  direction,  markedly 
inco-ordinate,  and  differ  in  character 
from  any  other  form  of  abnormal  motor 
discharge  known.  They  result  in  sudden 
grimaces  and  facial  twitchings;  sudden 
closure  and  opening  of  the  eyes  or  mouth; 
sudden  seizure  and  immediate  dropping 
of  any  object  it  is  attempted  to  grasp; 
twisting  movements  of  the  arms;  pe- 
culiar dancing  and  bobbing  movements 
of  the  feet,  all  of  these  movements  seem- 
ing at  times  semipurposeful,  leading  to 
the  idea  on  the  part  of  the  onlooker  that 
they  are  due  to  bad  habit  or  awkward- 
ness, and  could  be  prevented. 

The  movements  vary  in  intensity  from 
slight,  scarcely-noticeable  twitchings  of 
co-ordinate  groups  of  muscles,  occurring 
at  intervals,  to  violent  and  almost  con- 
tinuous clonic  spasmodic  contractions  of 
nearly  or  quite  all  of  the  voluntary  mus- 
cles of  the  body,  resulting  in  writhings 
and  contortions  which  completely  inca- 
pacitate the  patient  and  render  neces- 
sary confinement  to  bed.  The  move- 
ments may  occur  when  the  muscles  are 
at  rest,  but  they  are  often  precipitated  or 
intensified  by  voluntary  muscular  effort 
of  any  kind.  They  are  increased  by 
efforts  to  prevent  them  and  by  anything 
which  directs  attention  to  them.  They 
cease  entirely  during  sleep.  In  many 
cases  speech  is  affected  in  consequence 
of  implication  of  labial  muscles  and 
tongue,  giving  rise  to  peculiar  jerking 
out  of  words,  explosive  utterances,  hesi- 
tation, or  indistinctness  of  articulation 
which  may  in  some  cases  amount  to  en- 
tire inability  to  talk.  The  lips  are  occa- 
eionally  bitten;  the  tongue  rarely.    The 


muscles  of  respiration  may  become  in- 
volved, in  which  event  there  will  be  un- 
even, irregular  respiratory  movements, 
■ndth,  possibly,  sighing,  moaning,  or  other 
involuntary  inarticulate  sounds.  Deglu- 
tition in  severe  cases  is  also  more  or  less 
interfered  with,  and  the  patient  natu- 
rally finds  difficulty  in  feeding  himself, 
on  account  of  the  inco-ordinate  action  of 
the  muscles  of  the  arms  and  hands.  The 
urine  and  faeces  may  pass  involuntarily. 
The  gait  is,  in  all  well-marked  cases, 
altered,  and  is  usually  shuffling  and 
slow,  the  steps  being  unequal  in  length 
and  in  time,  with  difficulty  in  progress- 
ing in  a  straight  line. 

There  is  no  rigidity  nor  tonic  spasm. 
The  muscles  may  become  tender  to  press- 
ure. There  is  usually  some  muscular 
weakness  or  paresis,  which,  in  occasional 
cases,  becomes  extreme  ("paralytic  cho- 
rea"). The  tendon-reflexes  are  normal. 
Trophic  disorders  are  not  the  rule,  but 
erji;hema,  herpes  zoster,  or  chloasmic 
blotches  may  be  occasionally  seen. 

The  movements  are  rarely  general  at 
first.  They  begin  in  the  upper  ex- 
tremity, or  the  face,  or,  rarely,  in  the 
lower  extremity.  They  spread  over  the 
corresponding  half  of  the  body,  and 
finally  attack  the  opposite  side.  In  144 
cases  studied,  the  onset  was  general  in 
25  cases  only  and  hemilateral  in  111 
eases.  G.  Oddo  (Revue  de  Med.,  Jan.  10, 
1901). 

There  is  always  some  disorder,  usually 
a  general  dulling  of  tactile  temperature 
and  muscular  sense.  In  the  early  stages 
pain  is  frequent,  but  in  later  stages  this 
gives  place  to  well-marked  analgesia. 
Prickling,  formication,  and  other  panes- 
thcsia;  are  common. 

In  uncomplicated  cases  the  pupillary 
reactions  are  normal. 

Psychical  abnormalities  are  the  rule. 
These  vary  from  the  slight  irritability, 
weakness,  and  altered  disposition  com- 


172 


CHOREA.    SYMPTOMS. 


monly  seen  in  early  stages  to  marked 
intellectual  impairment  with  loss  of 
memory,  confusion  of  ideas,  inability  to 
concentrate  attention,  and  grave  emo- 
tional disorder  of  a  melancholic  cast. 
Occasionally  a  generalized  outburst  of 
acute  insanity  or  delirium  will  occur, 
giving  rise  to  the  clinical  subdivision 
"chorea  insaniens." 

Chorea  an  infectious  disease.  Like  all 
other  infectious  diseases,  its  toxic  prin- 
ciple may  give  rise  to  insanity  with  hal- 
lucinations, modified  in  form  according 
to  individual  peculiarities.  Ihe  onset  of 
the  insanity  is,  like  all  insanities  of  toxic 
origin,  sudden,  and  its  progress  acute  or 
subacute.  Usually  there  is  no  parallel- 
ism between  the  choreic  movements  and 
the  mental  symptoms;  but  it  is  to  be 
noted  that,  while  chorea  generally  occurs 
in  patients  about  15  years  of  age,  mental 
disturbance  is  generally  found  in  choreic 
patients  of  19  years  of  age.  P.  J.  Mobiua 
(Miinchener  med.  Woch.,  Dec.  20,  27, 
'92). 

A  true  aphasia  has  been  noted  in  a 
few  instances,  usually  associated  with  a 
right  hemichorea. 

Along  with  the  nervous  symptoms 
above  described  in  detail  there  are,  in 
most  cases,  some  evidences  of  disorder 
of  the  general  bodily  functions.  Fever 
is  present  at  some  stage,  usually  early, 
in  a  majority  of  cases.  When  slight  and 
maniacal  chorea  is  present  a  tempera- 
ture of  103°  to  104°  F.  is  often  noted. 
A  decided  rise  is  usual  in  cases  show- 
ing complications,  such  as  rheumatism, 
pericarditis,  or  endocarditis. 

The  renal  function  is,  in  mild  uncom- 
plicated cases,  normal.  In  the  severe 
cases  and  in  almost  all  febrile  cases  al- 
buminuria exists,  and  the  amount  of  urea 
excreted  is  in  excess  of  the  normal.  In 
maniacal  chorea  there  is,  as  a  rule,  a  dis- 
tinct nephritis. 

Cardiac  irregularity  with  abnormal 
rapidity  of  action  is  not  infrequent,  and 


of  all  the  complications  of  chorea,  peri- 
carditis and  endocarditis  are  most  often 
seen,  the  latter,  especially,  occurring,  ac- 
cording to  Osier,  in  quite  one-half  of  all 
cases.  Cardiac  murmurs,  due  to  the  en- 
docarditis and  also  in  some  instances  to 
impoverished  blood,  are  common.  A 
true  anfemia — diminution  in  liaBmoglo- 
bin-percentage  and  in  number  of  red 
and  white  corpuscles — is  often  noted. 

In  a  limited  number  of  cases  symptoms 
of  gastro-intestinal  disorder  occur,  the 
sj'mptoms  being  those  shown  in  cases  of 
autoinfection. 

Since  chorea  occurs  by  preference  in 
children  of  neurotic  heredity,  the  psy- 
chical, physiological,  and  anatomical 
stigmata  of  degeneracy  in  greater  or  less 
prominence  are  often  added  to  the  symp- 
toms above  detailed. 

Three  grades  of  the  disease  are  de- 
scribed: The  mild,  in  which  there  is 
little  disturbance  of  general  health,  no 
complications,  and  only  moderately-well- 
marked  choreic  movements;  the  severe, 
in  which  fever,  mental  disorder,  and 
other  complications  are  present,  and  the 
inco-ordinate  clonic  spasms  more  severe 
and  continuous,  with  well-pronoimced 
muscular  weakness;  and  the  violent 
"chorea  insaniens,"  characterized  by 
rapid  onset  and  progress,  violent  and  con- 
tinuous choreoid  spasm,  with  fever  and 
delirium,  terminating  not  infrequently 
in  death. 

Motor  symptoms  in  chorea  arranged  in 
five  clinical  groups:  1.  Cases  in  which 
there  is  at  some  stage  absence  of  the  mo- 
tions when  at  rest.  2.  Cases  in  which 
tlie  movements  are  less  when  the  child 
is  at  rest,  but  are  aggravated  by  volun- 
tary movements.  3.  Cases  in  which  the 
severe  choreiform  movements  disappear 
during  voluntary  movements.  4.  Cases 
in  which  voluntary  exertion  does  not  in- 
fluence the  movements.  5.  Cases  present- 
ing at  different  stages  more  than  one 
of  tlie  above  types.     Weir  Mitchell  and 


CHOREA.     DIAGNOSIS.     ETIOLOGY  AND  PATHOLOGY. 


173 


J.  H.  W.  Rhein  (Phila.  Med.  Jour.,  Jan. 
22,  '98). 

Ciagnosis. — In  typical  cases  no  great 
difSculties  in  diagnosis  are  presented, 
the  characteristic  muscular  movements 
being,  in  themselves,  sufficient  to  make 
the  nature  of  the  case  plain.  In  atypical 
forms  some  doubt  may  arise,  and  there 
are  a  few  other  states  which  may  be  con- 
founded with  acute  chorea.  Thus,  in 
hysteria  choreiform  movements  suggest- 
ing chorea  may  take  place  ("hysterical 
chorea").  The  ansesthesia  and  accom- 
panying symptoms  discoverable  upon 
examination,  together  with  the  fact  that 
in  hysteria  the  movements  are  more 
rhythmical  than  in  chorea,  should  make 
a  diagnosis  easy. 

The  muscular  weakness  may  be  so  ex- 
treme as  to  suggest  acute  anterior  poli- 
omyelitis. The  presence  of  the  choreic 
movements  are,  however,  enough  to  ex- 
clude poliomyelitis.  Some  forms  of  scle- 
rosis and  degenerative  changes  in  the 
cerebral  cortex  are  attended  by  chorei- 
form movements,  and  may,  when  occur- 
ring in  young  persons,  lead  to  thought 
of  acute  chorea.  The  presence  of  mental 
disorder,  exaggerated  reflexes,  muscular 
rigidity,  and  other  spastic  symptoms 
should  prevent  mistake.  Friedreich's 
ataxia  was  formerly  and  is  still  some- 
times mistaken  for  chorea  by  those  un- 
familiar with  the  symptomatology  of 
nervous  diseases.  The  scanning  speech, 
nystagmus,  and  the  irregular,  slow,  and 
peculiar  inco-ordinate  movements  of 
Friedreich's  ataxia  are  sufficiently  dif- 
ferent from  the  clinical  picture  of  chorea 
to  prevent  confusion  if  a  proper  examina- 
tion is  made. 

Involuntary  movement,  muscular 
weakness,  and  niu.tcular  rigidity  arc 
three  symptoms  belonging  to  the  group 
that  depends  on  impaired  functional  in- 
tegrity of  the  upper  segment  of  the 
motor   path.     They    are    found    in    two 


diseases  which  are  due,  not  to  structural, 
but  to  functional  or,  perhaps,  rather  nu- 
tritional changes  in  the  cortex,  viz.:  pa- 
ralysis agitans  and  chorea,  which  have 
a  certain  kinship  to  one  another,  the 
former  being  commonly  heniiplegic  in  its 
mode  of  commencement  and  e.\tension, 
while  the  other  is  frequently  hemiplegic 
in  its  distribution  throughout  its  entire 
course.  In  the  case  of  chorea  the  ab- 
normal movements  are  so  obtrusive  in 
comparison  with  the  others  that  there  is 
danger  of  the  latter  being  overlooked, 
although  weakness,  at  any  rate,  is  now 
generally  known  as  a  frequent  symptom. 
In  exceptional  instances  weakness  may 
be  practically  the  only  symptom,  and 
the  diagnosis  may  then  be  somewhat  dif- 
ficult. The  age  of  the  patient,  the  limita- 
tion of  the  weakness  to  one  arm,  and 
the  occasional  manifestation  of  slight 
choreic  movements  in  the  affected  limb 
or  in  other  parts  may  furnish  the  neces- 
sary clue.  Jlonroe  (Glasgow  Med,  Jour., 
Feb.,  '97). 

Peculiarities  of  the  knee-jerk.    If,  the 
patient  being  in  the  recumbent  position, 
one  raises  the  knee,  allowing  the  heel 
to  rest  on  the  couch,  making  sure  that 
all  the  muscles  of  the  limbs  are  relaxed 
for   the    time   being,   and   if   one   then 
tests  the  knee-jerk   in  the  usual  way, 
the  foot  is  found  to  ri.se  more  or  less 
smartly,  but,  instead  of  falling  back  im- 
mediately, it  remains  suspended  for  a 
variable   time — hung   up,   as   it   were — 
and  then  slowly  sinks  back  to  its  initial 
position.    W.  Gordon  (Brit.  Med.  Jour., 
Mar.  30,  1001). 
Etiolo^  and  Pathology. — In  general 
terms,  choreic  movements  of  all  kinds 
are  primarily  due  to  inherent  neuronic 
weakness    or    instability,    especially    in 
motor    sphere,    with    abnormally-devel- 
oped motor  association-tracts,  or  to  de- 
fective insulation  in  lines  of  motor  dis- 
charge. 

An  unstable  condition  of  the  higher 
nerve-centres  predisposes  to  the  condi- 
tion, and  a  poison  affecting  these  centres 
might  produce  in  one  person  epilepsy, 
in  another  general  neurasthenia,  and  in 
a  third  chorea.  Bishop  (Can.  Pract.. 
Nov.,  '97). 


174 


CHOREA.    ETIOLOGY  AKD  PATHOLOGY. 


Chorea  considered  a  condition  of  ex- 
hausted nerve-control.  Upon  this  theory 
the  association  of  chorea  and  rheumatism 
seems  to  be  readily  explained.  As  a  re- 
sult of  the  rheumatic  poison  there  oc- 
curs a  failure  in  the  nutrition  of  the 
nerve-cells  regulating  and  balancing  mus- 
cular movements,  and  thus  in  certain 
individuals  of  neurotic  tendency  rheuma- 
tism becomes  the  causative  factor  of 
chorea.  G.  M.  Swift  (Archives  of  Pedi- 
atrics, Sept.,  '99). 

The  immediate  exciting  cause  is  irri- 
tation of  cortical  motor  neurones  from 
toxic  substances  in  the  blood  due  to  in- 
fectious diseases,  autointoxications,  etc., 
nerve-cell  fatigue,  and  in  some  cases  tem- 
porarily induced  abnormal  "neuronic 
contacts"  in  sensorimotor  sphere  from 
sudden  shock  or  emotion. 

In  the  form  of  acute  chorea  under 
consideration  the  neurotic  constitution 
with  the  anatomical  and  physiological 
stigma  of  degeneration  can  usually  be 
traced.  Ancemia  with  general  bodily  en- 
feeblement  is  common. 

Study  of  40  cases.  The  blood  is  rarely 
absolutely  normal  in  amount  of  coloring 
matter  and  number  of  red  corpuscles 
during  an  attack.  There  is  usually  a 
moderate  diminution  in  the  hjEmoglobin 
and  a  relatively  slighter  decrease  in  the 
number  of  red  corpuscles;  in  other 
words,  the  anemia  is  chlorotic  in  type. 
There  is  no  relation  between  the  severity 
of  the  aneeraia  and  that  of  the  attack, 
and  when  the  latter  is  profound  there  is 
usually  some  complication  competent  to 
explain  it.  Ana;mia  is  not  an  immediate, 
direct,  exciting  cause,  but  frequently  a 
predisposing  one.  Burr  (Pediatrics,  Feb. 
1,  '97). 

Nearly  all  tlie  cases  show  blood- 
changes  and  leucocytosis.  In  a  few  cases 
marked  increase  in  the  amoeboid  move- 
ment of  the  white  corpuscles  observed 
and  a  possible  diminution  of  the  eosino- 
phile  or  orthophiles  among  the  white 
corpuBcleB.  In  all  cases  the  condition  of 
the  blood  is  of  great  importance  in  estab- 
lishing a  prognosis.    In  the  further  study 


of  chorea  its  hiematology  is  of  the  great- 
est importance,  and  the  clinical  aspects 
of  the  disease  point  to  an  infectious  ori- 
gin.   Loudon  (Clin.  Med.  Rec,  Dec, '97). 

Two  hundred  cases  of  chorea  analyzed. 
One  hundred  and  thirty-six  of  the  pa- 
tients were  females  and  64  males.  After 
IS  years,  3  cases  were  found  among  men 
and  10  among  women.  Thirty-seven 
cases  occurred  after  the  establishment  of 
the  menstrual  function  and  99  before. 
A  neuropathic  heredity  and  anomalies 
of  the  cranium  play  an  undoubted  rSle. 
This  nervous  heredity  was  clearly  estab- 
lished in  73  cases,  of  which  49  were  in 
females  (with  9  cases  of  homologous 
heredity)  and  24  in  males  (with  3  cases 
of  homologous  heredity).  Anomalies  of 
the  cranium  were  very  frequent,  most 
often  produced  by  rachitism,  and  belong- 
ing to  an  hydrocephalic  type,  more  rarely 
to  a  Bubmicrocephalic  type,  and  more 
rarely  still  to  a  phagiocephalic  type. 
Among  other  causes  responsible  for  nerv- 
ous predisposition  are  masturbation, 
acute  diseases,  concussion  of  the  brain, 
and  pregnancy.  Exciting  causes  in  a  cer- 
tain number  of  eases  were  articular 
rheumatism  and  infectious  diseases,  in 
others  psychical  traumatism.  Influence 
of  infectious  maladies  was  manifest  in  75 
cases;  in  58  of  these  there  was  acute 
articular  rheumatism,  with  or  without 
cardiac  lesions.  Of  75  post-infectious 
cases  a  nervous  predisposition  was  pres- 
ent only  in  50.  In  cases  in  which  chorea 
developed  after  a  psychical  traumatism 
the  role  of  neuropathic  heredity  was 
much  more  manifest.  Of  the  CO  cases  of 
this  class  such  heredity  existed  in  64  pa- 
tients. Psychical  traumatism  most  often 
was  of  the  nature  of  a  fright.  In  59 
cases  the  exciting  cause  could  not  be  as- 
certained. Kraft-Ebing  (Wiener  klin. 
Woch.,  No.  43,  '99). 

The  urine  in  Sydenham's  chorea 
presents  the  following  characteristics: 
Diminution  of  the  daily  quantity;  spe- 
cific gravity  relatively  high;  total  acid- 
ity increased;  diminution  during  the 
disease  of  the  quantity  of  nitrogen 
which  is  not  eliminated  as  urea;  in- 
creased elimination  of  uric  acid;  de- 
crease in  elimination  of  chlorides;  in- 
crease of  phosphates;    total  quantity  of 


CHOREA.     ETIOLOGY  AND  PATHOLOGY. 


175 


sulphuric  acid  and  allied  substances, 
unchanged.  De  Marchis  (La  Riforma 
Medica,  July  5,  1002). 

Some  cases  develop  without  any  dis- 
coverable exciting  cause,  but  in  most 
instances  the  onset  of  the  chorea  is  pre- 
ceded by  mental  strain,  worry,  or  shock 
of  some  kind — overwork  at  school,  fear, 
religious  emotion,  etc. — or  by  the  occur- 
rence of  some  infectious  disease  or  tox- 
emic state,  such  as  rheumatism. 

Chorea  is  a  symptom,  and  not  a  dis- 
ease, the  principal  cause  being  rheuma- 
tism acting  on  a  nervous  subject.  Duck- 
worth (Brooklyn  Med.  Jour.,  May,  '92). 

In  134  out  of  19G  eases  of  chorea  rheu- 
matism was  present.  In  the  majority  of 
cases  chorea  is  the  result  of  rheumatic 
diathesis,  although  cases  occur  which 
must  be  considered  as  true  neuroses.  SCe 
(La  M6d.  Mod.,  Oct.  15,  22,  '91). 

Study  of  the  seasonal  relations  of 
chorea  and  rheumatism  for  a  period  of 
fifteen  years.  Chorea  and  rheumatism 
are  periodical,  the  least  severe  attacks 
in  chorea  occurring  in  October  and  No- 
vember and 'the  most  severe  in  March 
and  April.  It  is  the  same  in  rheumatism. 
These  two  affections  are  considered  to 
have  the  same  causal  relation  with  mete- 
orological conditions.  Morris  Lewis 
(Boston  Med.  and  Surg.  Jour.,  June  23, 
'92). 

Chorea  is  nearly  always  secondary  to 
acute  articular  rheumatism,  or  to  some 
infectious  disease.  An  efficient  part  is 
played  by  the  mental  emotions.  In  19 
of  70  cases  there  was  no  family  history 
of  disease,  but  an  unobserved  previous 
infection  suspected.  In  14  cases  there 
were  cardiac  lesions,  and  in  G  of  the  14 
the  chorea  was  unmistakably  of  rheu- 
matic origin ;  further,  there  is  an  etio- 
logical identity  between  chorea  and  en- 
docarditis. Marfan  (Revue  Mens,  des 
Mai.  de  I'Knf.,  Aug.,  '97). 

Chorea  is  nothing  else  but  one  of  the 
n\imorous  manifestations  of  rhcunuitism, 
for  the  following  reasons:  It  alTects  the 
same  geographic  distribution:  like  rheu- 
matism, it  is  most  frequent  in  cold  coun- 
tries;  it   shows  its  preference  for  damp 


seasons;  besides,  if  choreic  patients  are 
examined  with  care,  it  will  be  found  that 
cardiac  afl'ections  are  frequent,  even 
though  they  may  not  have  had  rheu- 
matic antecedents.  One  of  the  argu- 
ments against  a  rheumatic  origin  is  that 
the  disease  is  not  modified  by  sodium 
salicylate,  but  this  same  drug  is  equally 
ineffective  as  regards  endocarditis,  cu- 
taneous eruptions,  etc.  Simon  (Jled. 
Press  and  Circular,  Apr.  7,  '97). 

Histories  of  1400  cases  of  chorea  seen 
in  Vanderbilt  Clinic  shows  proportion  of 
females  a  fleeted  compared  with  males 
was  almost  2  to  1;  the  disease  is  more 
common  in  the  poorer  classes.  Heredity 
and  infectious  diseases  seemed  to  bear 
no  definite  relation  to  the  disease,  the 
most  constant  element  being  malnutri- 
tion. Fright  immediately  before  onset 
was  noted  in  285  cases,  and  290  had  dis- 
tinct history  of  true  rheumatism.  Or- 
ganic heart-murmurs  were  present  in  175 
cases,  functional  in  123,  and  none  in  871. 
Nine  hundred  and  nineteen  cases  oc- 
curred between  the  ages  of  seven  and 
fourteen  years;  of  1129  cases,  707  came 
on  between  March  and  August.  Recur- 
rences present  in  one-fourth  of  the  cases, 
were  most  common  in  the  spring.  Cho- 
reic movements  were  general  in  951 
cases,  unilateral  in  449,  the  right  side 
being  afi"ected  slightly  more  than  the 
left.  Mental  irritability  was  noted  in 
827  and  speech  was  affected  in  550.  M. 
Allen  Starr  ("Abraham  Jacobi  Fest- 
schrift"; Phila.  Med.  Jour.,  May  20, 
1900). 

The  theory  of  the  infective  genesis  of 
chorea  (rheumatic)  points  out  that  a 
negative  bacteriological  result  need  not 
exclude  micro-organisms  as  a  cause,  for 
this  may  result  from  several  causes: 
for  e.xample,  spontaneous  attenuation  of 
the  micro-organisms,  germicidal  action 
of  organic  fluids,  plasmolysis,  irregular 
distribution  of  the  bacilli,  occlusion  (in- 
flammatory) of  the  communicating  chan- 
nel between  the  internal  cavities  of  the 
brain  and  the  perimedullary  spaces, 
stratification  of  the  bacilli  in  different 
layers  of  the  fluid,  or  insufficiency  of 
material  taken  for  test  purposes.  Any 
one  of  these  causes  might  account  for 
a  negative  result  in  testing  for  bacilli. 


176 


CHOREA.    ETIOLOGY  AND  PATHOLOGY. 


and  taken  together  they  may  explain 
the  cases  of  rheumatic  chorea  where 
germs  have  not  been  discovered.  And 
since  every  day  seems  to  show  more 
clearly  an  association  between  rheuma- 
tism and  the  various  pyogenic  organ- 
isms, it  is  these  that  one  looks  for  in 
chorea.  The  non-rheumatic  choreas  may 
be  due  to  germs  not  easily  cultivated. 
Mircoli  (Gazz.  degli  Osped.,  Nov.  23, 
1902). 

Measles,  whooping-cough,  influenza, 
diphtheria,  scarlet  fever,  endocarditis, 
malaria,  urinary  abnormalities,  aggra- 
vated constipation,  etc.,  are  also  impor- 
tant factors. 

Query  whether  chorea  should  be  con- 
sidered a  sequel  of  scarlet  fever  or  not. 
Cheadle  recognizes  it  as  such,  but  quali- 
fies the  opinion  by  adding  that,  in  1894 
and  1896,  83G0  cases  of  scarlet  fever  were 
under  treatment  at  the  Northeastern 
Hospital,  and  of  these  5355  were  com- 
pleted there.  Thirteen  cases  of  chorea 
were  observed,  or  1  in  412  completed 
eases.  Osier  found  1  case  of  chorea  to 
every  180  patients.  Hence  it  would  ap- 
pear that  chorea  is  less  frequent  among 
scarlet-fever  patients  than  among  pa- 
tients in  general.  Of  Osier's  13  cases,  5 
had  rheumatic  manifestations,  which,  in 
each  instance,  immediately  preceded,  or 
appeared  simultaneously  with,  the 
chorea.  Rheumatism  or  joint-affection 
which  occurs  as  a  complication  of  scarlet 
fever  sets  in  toward  the  end  of  the  first 
week;  but  in  these  cases  it  was  consid- 
erably later,  indicating  a  difTerence  in 
the  nature  of  the  joint-afTection.  Priest- 
ley (Brit.  Med.  Jour.,  Sept.  25,  '97). 

A  case  of  paralysis  and  chorea  as  a 
sequel  to  scarlet  fever.  That  the  scarlat- 
inal attack  bore  a  causative  relation  to 
the  growth  of  the  nervous  condition  there 
can  be  no  doubt.  Cornell  (Medicine,  Jan., 
'98). 

From  a  study  of  239  cases  of  chorea 
gravidarum  it  was  found  that  the  chorea 
frequently  appears  in  a  patient  who  bus 
Buffered  from  Uie  ordinary  form  on  some 
previous  occasion.  Chorea  gravidarum 
may  come  on  gradually  or  suddenly,  and 
in  the  latter  case  is  not  infrequently  due 


to  a  sudden  fright  or  emotion.  The  onset 
of  the  chorea  may  be  accompanied  by 
globus  and  other  symptoms.  Many  of 
these  cases  show  extreme  constipation. 
Mastier  (Th&se  de  Lyon,  '99). 

In  over  71  per  cent,  an  infectious 
etiology  could  be  obtained  in  chorea. 
Not  only  are  endocarditis  and  articular 
rheumatism  frequently  mentioned  in  the 
past  history,  but  often  some  catarrhal 
condition  of  the  respiratory  tract,  as 
angina,  bronchitis,  laryngitis,  or  influ- 
enza, seems  to  be  the  precursor,  alone 
or  in  various  combinations.  Of  the  non- 
infectious cases,  the  majority  of  patients 
possessed  a  neuropathic  tendency  and 
were  considerably  run  down,  through 
rapid  growth,  overexertion,  or  insuf- 
ficient nourishment,  and  frequently 
showed  the  stigmata  of  a  past  rachitis 
or  scrofulosis.  Here  the  most  fre- 
quently mentioned  cause  seemed  to  be 
fright,  and  often  hysteria  played  an  im- 
portant part.  G.  Koster  (Miinchener 
raed.  Wochen.,  Aug.  12,  1902). 

Eheumatism  is  the  most  important  eti- 
ological factor  of  chorea,  the  cardiac  le- 
sions being  closely  associated  with  it. 
Both  the  rheumatic  diathesis  and  cardiac 
morbid  conditions  predispose  to  the  dis- 
ease. 

Study  of  the  relations  existing  between 
chorea,  rheumatism,  and  diseases  of  the 
heart:  1.  Neither  rheumatism  nor  heart 
disease  is  essential  to  chorea.  2.  The 
preponderance  of  evidence  points  toward 
the  conclusion  not  only  that  rheumatism 
and  organic  heart  disease  conjointly  ap- 
pear more  frequently  in  the  choreic  sub- 
ject than  can  be  accounted  for  by  coin- 
cidence, but  that  the  same  is  true  of  each 
of  these  afl'cctions  separately.  It  follows, 
therefore,  tliat  rheumatism  predisposes  to 
eliorea,  and  organic  heart  disease  has  the 
same  tendency.  3.  Fatal  cases  are  gen- 
erally associated  with  organic  heart  dis- 
ease, and  probably  with  organic  disease 
of  the  central  nervous  system,  notably 
cerebral  embolism.  4.  There  is  a  largo 
class  of  functional  cases,  mainly  reflex 
and  fostered  by  circumstances  tending 
to  produce  functional  symptoms  in  gen- 
eral.   5.  The  pathological  connection  be- 


CHOREA.    ETIOLOGY  AND  PATHOLOGY. 


177 


tween  rheumatism  and  chorea,  except- 
ing in  the  cases  where  emboli  are  pro- 
duced by  accompanying  endocarditis,  is 
still  obscure;  probably  no  one  theory  is 
applicable  to  all  cases.  G.  The  meclian- 
ism  by  which  the  peculiar  phenomena  of 
chorea  are  produced  is  unknown.  Walton 
and  Vickery  (Amer.  Jour.  Med.  Sci., 
May,  '92). 

Examination  of  140  persons  having 
suffered  from  chorea  at  least  two  years 
previously.  In  51,  heart  normal;  in  72, 
symptoms  of  organic  lesion;  in  17,  car- 
diac disturbances.  No  rheumatic  history 
in  Cli  per  cent.  Cause:  an  infection  al- 
lied to  rheumatism,  but  differing  from 
it.    Osier  (Pacific  Med.  Jour.,  Aug.,  '95). 

Si.\  cases,  all  in  young  women  of  ages 
varying  from  17  to  21,  in  which  the  dis- 
ease was  very  grave,  and  proved  fatal  in 
two.  The  previous  association  of  scarla- 
tina or  rheumatism — articular,  endocar- 
dial, and  prtecordial — noted  in  every 
case;  likewise  recurrence  of  chorea  on 
the  same  side  as  the  former  rheumatic 
affection  had  existed.  Napier  (Glasgow 
Med.  Jour.,  Feb.,  '97). 

Out  of  20  choreic  patients  personally 
examined,  in  7  there  was  a  previous 
history  of  rheumatic  fever  in  the  pa- 
tient; in  4  there  was  a  strong  family 
.  history  of  rheumatic  fever,  and  in  the 
remaining  9  there  was  no  history  of  rheu- 
matic fever,  but,  out  of  these  9,  2  had 
mitral  stenosis,  5  had  mitral  regurgita- 
tion, and  only  2  had  no  valvular  affection 
of  the  heart.  Out  of  the  20  cases,  5 
gave  a  history  of  fright  or  shock.  In  the 
20  eases  18  came  on  between  the  fourth 
and  the  fifteenth  year,  5  of  which  oc- 
curred at  the  fourteenth  or  fifteenth  year. 
This  refers  only  to  first  attacks  of  chorea. 
Sixteen  occurred  in  females  and  only  4 
in  males.  Purves  Stewart  (Med.  Brief, 
June,  '98). 

About  21  per  cent,  of  all  choreic  cases 
give  a  rheumatic  history,  either  in  their 
parents  or  themselves  prior  to  the  disease. 
Chorea  follows  an  atUick  of  scarlet  fever 
in  children  in  abotit  25  per  cent,  of  all 
eases.  Forcing  children  at  school  is  a 
most  important  factor  in  producing  the 
disease.  Ocular  defects  may  lie  at  the 
bottom  of  some  cases  of  chorea.  Edwin 
Williams  (Memphis  Lancet,  Aug.,  '99). 

2—12 


View  that  chorea  is  associated  with 
rheumatism  opposed.  Of  seventeen  con- 
secutive cases  of  chorea  at  personal  clinic, 
only  one  had  rheumatism  before  or  dur- 
ing the  attack,  and  of  several  who  re- 
turned after  recovery  none  had  shown 
any  sign  of  the  latter  disease.  Gilles  de 
la  Tourette  (Rev.  Neurol.,  June  30, 
1900). 

Forty-seven  cases  of  chorea  minor 
studied.  Age  of  patients  varied  from  3 
to  IC  years,  and  in  28  the  disease  had 
begun  from  seven  to  eleven  years  pre- 
viously; 39  were  girls  and  8  boys.  In 
24  cases  there  was  the  family  history  of 
rheumatism  or  of  psychical  affections. 
Among  the  47  there  were  15  who  had 
had  rheumatic  fever,  either  before  or  dur- 
ing the  chorea,  and  in  10  chorea  had  be- 
gun or  had  been  accompanied  by  febrile 
phenomena  with  angina,  articular  affec- 
tions, or  erythema  nodosum.  T.  Frolich 
(Norsk  Mag.  f.  Laegevidensk.,  Sept., 
1900). 

The  frequency  of  fibrinous  accretions 
upon  the  cardiac  valves  and  the  undis- 
puted frequency  of  embolism  of  the 
cerebral  arteries  give  origin  to  the  often- 
mentioned  "embolic  theory"  of  the  causa- 
tion of  chorea,  a  theory  first  advanced 
by  Kirkes  and  supported  especially  by 
Hughlings-.Tackson,  according  to  which 
the  inco-ordinate  movements  of  chorea 
are  due  to  multiple  capillary  embolism 
of  the  corpus  striatum.  This  explana- 
tion is,  however,  somewhat  far-fetched 
and  it  is  also  insufficient,  since  there  are 
many  cases  of  chorea  which  show  no  evi- 
dence of  embolism  and  in  which  there  is 
no  endocarditis. 

A  specific  microbic  origin  has  been 
suggested,  but  is,  as  yet,  not  demon- 
strated. 

Hints  at  the  possibility  of  an  infectious 
origin  for  chorea.  Report  of  a  ca^e  of 
chnrca  insanini.^  in  a  woman  of  27,  who 
had  had  two  attacks  of  rheumatism,  and, 
with  the  second,  had  had  delirium  and 
irregular  movements  of  the  limbs.  The 
autopsy  showed  an  acute  endocarditis, 
abscess   of   the   parotid,    and    catarrhal 


178 


CHOKEA.     ETIOLOGY  AND  PATHOLOGY. 


pneumonia  of  both  lungs.  No  special 
germ,  however,  could  be  discovered. 
Chorea  is  a  general  systemic  affection, 
acting  with  greatest  intensity  upon  the 
vascular  system  and  the  leptomeninges; 
its  cause  is  to  be  sought  for  in  a  special 
bacillus.  Berkley  (Johns  Hopkins  Hosp. 
Eep.,  Aug.,  "91). 

Autopsy  of  a  case  in  which  micro- 
scopical examination  showed  a  conspicu- 
ous chronic  leptomeningitis  involving  the 
vertex  of  the  brain ;  a  proliferating  proc- 
ess, without  exudation  or  much  cell- 
infiltration.  In  the  superficial  layer  of 
the  cortex  there  was  cellular  infiltration 
with  degenerative  changes.  At  this 
point  a  diplococeus  was  found.  The 
micro-organisms  were  observed  only  in 
the  deep  layer  of  the  pia  and  the  super- 
ficial part  of  the  cortex.  Dana  (N.  Y. 
Med.  Jour.,  Aug.  19,  '93). 

Study  of  600  cases.  The  toxin  of 
chorea  may  be  a  glycocin,  for  which 
reason  micro-organisms  will  not  be  found 
in  the  blood.  No  light  thrown  upon  the 
connection  of  arthritis  and  chorea  nor 
any  explanation  advanced  why  the  toxin 
settles  in  the  brain  when  chorea  occurs 
in  rheumatic  subjects.  Failed  to  find 
any  cases  of  rheumatism  caused  by  fright 
or  any  of  chorea  primarily  induced  by 
chill.    Churton  (Med.  News,  Dec.  4,  '97). 

Study  of  choreics  bacteriologically,  and 
discovery  of  a  lanceolate  encapsulated 
diplococeus  extremely  pathogenic  to 
guinea-pigs,  in  which  it  determines  an 
liffimorrhagic  hypercemia  with  diminished 
fibrin  and  no  cedema.  The  histological 
lesions  in  the  nervous  system  of  patients 
and  in  the  viscera  of  the  guinea-pigs 
showed  that  the  effect  was  more  toxic 
than  septic,  with  an  elective  action  on 
the  vessels.  The  findings  appear  to  sus- 
tain Leroux's  theory  that  chorea  is  a 
syndrome  determined  by  some  infective 
or  toxic  agent  on  a  soil  prepared  by  an 
inheritance  of  neurotic  and  arthritic 
tendencies.  Mci  (Gaz.  degli  Osp.  et  delle 
Clin.,  Aug.  22,  '07). 

Conclusions  regarding  etiology  of 
chorea  arc  (1)  rheumatic  chorea  is  in- 
fective, and  depends  on  the  action  of 
toxins  of  micro-organisms  on  the  nervous 
Bystem;  (2)  staphylococci  are  the  chief 
source   of   infection,   in   that   they   have 


been  found  twice  as  often  as  all  the 
other  organisms  put  together.  Maragli- 
ano  (Centralb.  f.  innere  Med.,  xx,  p.  489, 
'99). 

While  the  importance  of  the  pyogenic 
micro-organisms  in  relation  to  chorea  is 
generally  recognized,  recent  bacteriolog- 
ical examinations  of  the  spinal  fluid  of 
choreic  patients  go  to  show  that  the 
relation  is  a  closer  one  than  is  usually 
supposed.  Staphylococci  found  in  the 
cerebro-spinal  fluid  in  two  personal 
cases.  In  a  third  case  of  erysipelas, 
which  was  followed  by  chorea  of  a  se- 
vere type,  not  only  had  lumbar  puncture 
a  favorable  therapeutic  effect  on  the 
movements  and  the  sleeplessness,  but 
also  streptococci  were  demonstrated  in 
the  fluid.  In  both  the  blood  and  urine  of 
this  case  streptococci  were  also  found. 
The  statistics  of  Triboulet  show  that  a 
third  of  all  chorea  cases  furnish  a  his- 
tory of  an  antecedent  febrile  attack,  of 
which  the  most  common  are  scarlatina, 
measles,  and  erysipelas.  In  all  cases  of 
chorea  the  cerebro-spinal  fluid  should  be 
examined.  Fornaca  (Riforma  Medica, 
No.  74,  1901). 

Chorea  is  not  infrequently  an  infec- 
tious disease ;  it  is,  therefore,  necessary 
to  make  a  bacteriological  examination 
of  the  blood  in  every  case.  Not  rarely 
the  disease  is  of  streptococcic  origin. 
In  polyvalent  antistreptococcic  serum 
we  possess  a  rational  remedy  for  the 
treatment  of  appropriate  cases  of  this 
disease.  P.  A.  Preobrazshonsky  (Meili- 
zinskoje  Obozrcnije,  vol.  Iviii,  No.  21, 
1902). 

Other  suggested  causes  are  cerebral 
hyperseniia,  capillary  thrombosis,  and 
prolonged  arterial  spasm;  but  none  of 
these  theories  odor  so  rational  an  ex- 
planation of  the  observed  symptoms  as 
that  which  attributes  the  choreiform 
movements  to  inherent  instability  in 
sensorimotor  sphere,  together  with  a  tox- 
lEmia  or  a  shock  sulTicient  to  disarrange 
the  customary  association-  or  contact- 
areas  in  cortex,  basal  ganglia,  and  cord. 

In  mild  cases,  should  death  occur,  it 
is  likely  that  no  characteristic  nor  well- 


CHOREA.    PROGNOSIS. 


179 


marked  anatomical  alterations  would  be 
detected.  In  severe  cases  there  are 
changes  in  the  neurone  bodies  of  the 
cerebral  cortex  and  lenticular  nuclei 
paralleling  those  of  fatigue,  as  de- 
scribed by  Hodges  and  others,  together 
with,  in  cases  of  long  standing,  distinct 
degenerative  changes  in  nervous  ele- 
ments of  the  cortex,  pyramidal  tracts, 
and  cord.  Wlien  these  degenerative  al- 
terations are  well  marked,  it  is  likely  that 
the  clinical  picture  during  life  was  that  of 
chronic  adult  chorea,  rather  than  Syden- 
ham's chorea.  In  addition  to  the  changes 
in  the  nervous  elements  themselves, 
there  are,  in  severe  and  long-continued 
cases,  secondary  changes  in  the  con- 
nective-tissue structures  and  blood-ves- 
sels, perivascular  dilatation,  accumula- 
tions of  round  cells  in  lymph-spaces,  etc. 
In  acute  cases  there  are  often  small  areas 
of  softening,  with  congestion  and  capil- 
lary dilatation  in  cortex  and  lenticular 
nuclei.  In  maniacal  chorea  the  cortex 
and  pia  mater  are  chiefly  involved,  there 
being  usually  intense  hyperemia,  with 
■evidences  of  acute  inflammation.  The 
changes  resemble  those  of  violent  acute 
mania  or  delirium. 

Report  of  thirty-nine  autopsies.  The 
chief  changes  were  just  beneath  the  cor- 
tex, where  the  white  matter  was  honey- 
combed with  little  spaces,  round  or  oval. 
These  spaces  were  empty  or  partly  filled 
with  blood-vessels.  The  process,  he  be- 
lieves, was  non-inllammatory,  and  was 
due  to  abnormal  dilatation  and  filtration 
of  the  vessels'  contents.  The  same 
changes  were  found  in  the  basal  ganglia 
and  the  internal  capsule,  whose  fibres 
were  split  up  by  interlaced  and  dilated 
vessels.  There  was  also  noticed  a  vari- 
cosity of  the  nerve-fibres.  In  the  re- 
corded cases  the  most  marked  changes 
were  hypcrsemia,  periarterial  exudations, 
erosions,  softened  spots,  multiple  htemor- 
rhagcs,  and  occasionally  embolisms.  The 
changes  are  most  marked  in  the  deeper 
parts  of  the  motor  tract ;    but  he  con- 


siders chorea  not  as  a  local  disease,  but 
as  a  disease  of  the  intracranial  motor 
tract,  including  its  starting-point  in  the 
cortex  and  especially  in  its  co-ordinating 
adjuncts, — the  lenticular  nucleus  and 
thalamus.    Dana  (Brain,  Oct.,  '90). 

An  aflection  of  cerebral  cortex.  Loss 
of  control  which  sensitive  areas  possess 
over  motor  areas.  Brush  (New  York 
Med.  Jour.,  Mar.  9,  '95). 

Case  of  a  girl  of  12,  in  whom  chorea 
set  in  six  weeks  after  a  first  attack  of 
acute  rheumatism  and  a  fortnight  after 
the  first  subjective  signs  of  cardiac  im- 
plication. Bronchitis,  and  eventually 
double  pneumonia,  supervened,  and  the 
patient  died  just  a  month  after  the 
commencement  of  the  chorea.  The  ne- 
cropsy was  made  four  hours  after  death, 
■which  was  found  to  be  due  to  double 
pneumonia,  with  staphylococcal  endo- 
carditis and  pericarditis.  Multiple 
thrombi,  colorless,  red,  mixed,  and  hy- 
aline, were  found  in  the  central  nerv- 
ous system,  particularly  the  cerebrum. 
There  was  a  deposit  of  clotty  masses  in 
the  adventitia,  of  a  medium-sized  vein 
in  the  globus  pallidus,  and  of  numerous 
fat-globules  in  and  on  the  cerebral 
blood-vessels.  There  had  been  a  con- 
siderable amount  of  sensory  disturbance 
in  the  ease,  due  probably  to  the  multiple 
thromboses.  The  symptoms  of  chorea 
due  to  vasomotor  disturbances  in  the 
brain  as  the  result  of  the  rheumatic 
toxffimia.  The  thromboses  are  the 
extreme  expression  of  these  changes. 
Okada  (Mitteil.  der  med.  Facult.  der 
kaiserl.  Japan,  Univ.  zu  Tokio,  1902). 

Prognosis. — The  rule  in  chorea  is  a 
gradual  and  insidious  onset,  a  slow  rise 
in  intensit}'  and  distinctness  of  symp- 
toms, followed  by  a  stationary  period  of 
weeks  or  several  months,  and  a  gradual 
subsidence  of  the  disease,  with  final  re- 
covery. The  malady  is  acute  and  quite 
curable,  with  a  natural  tendency  to  re- 
covery, even  when  not  treated  at  all. 
Some  mild  cases  recover  in  a  few  weeks; 
two  to  three  months  is  the  duration  of 
the  typical  forms,  although  occasionally 


180 


CHOREA.  TREATMENT  AND  PROPHYLAXIS. 


the  symptoms  may  persist  for  six  or  more 
months.  Some  nervousness  and  slight 
twitchings  noticed  when  the  child  is 
startled  or  excited  may  continue  for 
months  after  recovery,  and  a  species  of 
chronic  "habit  chorea"  may  be  the  final 
result.  A  true  chronic  chorea  rarely  or 
never  follows  this  variety  of  neurosis  in 
children,  but  is  occasionally  seen  after 
acute  chorea  in  adults.  In  general,  how- 
ever, a  chronic  chorea  in  adults  or  in 
children  is  apt  to  be  associated  with  de- 
generation of  the  cortical  motor  cells  and 
pyramidal  tracts,  thus  differing  widely 
from  the  form  of  acute  chorea  under 
consideration.  The  milder  forms  of 
chorea  are  \mattended  by  danger  to  life. 
Chorea  insaniens  is  often  fatal,  and, 
where  recovery  from  the  acute  affection 
occurs,  there  is  danger  of  some  perma- 
nent mental  deterioration. 

Kelapses  after  apparent  recovery  are 
not  rare.  The  existence  of  a  compli- 
cating rheumatism  or  endocarditis  is 
thought  to  favor  relapse. 

The  result  in  any  case  of  chorea  is 
largely  influenced  by  the  complications 
and  underlying  cause. 

Treatment  and  Prophylaxis. — In  view 
of  the  frequency  witli  which  chorea  de- 
velops in  intelligent  and  ambitious  chil- 
dren of  neurotic  heredity  who  are  over- 
worked at  school,  something  may  be 
done  toward  preventing  the  develop- 
ment of  the  disease  by  insisting  upon 
moderation  in  study  and  a  proper  ob- 
servance of  the  rules  of  physical  and 
mental  hygiene. 

Competition  for  prizes  and  any  other 
excess  in  school-work  should  be  for- 
bidden, and  the  child  encouraged  to 
spend  as  much  time  as  possible  out-of- 
doors,  in  healthy  games  and  play.  Drop- 
ping back  a  year  in  classes  will,  by  di- 
minishing amount  of  intellectual  effort 
required,  often  prove  of  decided  benefit. 


not  only  for  the  time  being,  but  in  all 
after-life.  An  epidemic  of  chorea-like 
hysterical  spasm  was  observed  in  a  girls' 
school  by  Laquer. 

Three  cases  of  arhytliraic  hysterical 
chorea  in  wliicli  the  hysteria  sliowed  all 
the  features  of  Sydenham's  chorea,  thus 
confirming  the  facts  previously  advanced 
by  Debove,  Merklen,  Chantemesse,  Jof- 
froy,  Sfglas,  Reque,  and  Perret.  B. 
Ouche  (Le  ProgrOs  Med.,  Dec.  5,  '91). 

Chorea  never  arises  in  healthy  children 
from  imitation,  but  in  all  cases  of  so- 
called  epidemics  we  have  to  do  with  an 
hysterical  afl'ection.  In  weak  and  poorly- 
nourished  children  chorea  is  often  devel- 
oped in  the  schools  from  overwork. 
Kiierner  (Deut.  med.  Woch.,  Apr.  2,  '91). 
The  co-existence  of  chorea  and  hysteria 
admitted  in  a  certain  number  of  cases, 
but  more  often  common  chorea  does  not 
arise  from  hysteria,  but  hysteria  is 
capable  of  simulating  it.  Dettling 
(These  de  Paris,  '92). 

Mental  disturbances  appearing  in 
chorea  divided  into  groups:  1.  Cases  of 
degenerative  disturbance  the  exacerba- 
tions of  which  are  often  accompanied  by 
choreic  or  amulsive  anomalies  of  move- 
ment. 2.  Lymphatic  posthemiplegic 
chorea  with  distinct  focal  brain  disease. 
3.  Imitative  chorea  or  anomalous  move- 
ments evoked  primarily  by  psychical 
or  traumatic  indignity;  these  are  mainly 
hysterical.  4.  Cases  of  Huntington's 
chorea,  which  is  analogous  to  paralytic 
dementia.  5.  Senile  chorea.  6.  Syden- 
ham's chorea,  which  may  be  character- 
ized by  elementary  psychical  disturb- 
ances, fleeting,  light  delirium,  the  symp- 
toms of  profound  neurasthenia,  stupor 
and  dementia,  or  by  complicating  psy- 
choses of  the  severest  form.  Von  Krafft- 
Kbing  (Wiener  kliii.  lUimlsclmu,  July  29, 
1900). 

Should  any  indication  of  chorea  ap- 
pear, the  ciiild  should  be  removed  from 
school  at  once  and  placed  in  as  good 
hygienic  circumstances  as  possible.  The 
cliild's  attention  should  not  be  directed 
toward  the  disease,  and  the  nervous  man- 
ifestations shovild  not  be  openly  noticed 
nor  commented  upon  by  others,  since 


CHOREA.     TREATIVLENT  AND  PROPHYLAXIS. 


181 


self-consciousness  and  suggestion  play 
an  important  part  in  exaggerating  the 
choreic  symptoms.  Eemoval  of  the  pa- 
tient from  home,  relatives,  and  familiar 
surroundings  will  go  far  toward  relieving 
the  condition.  A  trip  to  the  country  or 
to  the  sea-shore  when  possible  is  always 
beneficial.  Massage  and  hydrotherapeu- 
tic  measures  are  almost  always  indicated, 
and  do  especial  good  in  the  cases  in 
which  anffimia  and  general  debility  are 
present. 

Hydrotherapy;  wet  pack  best  method, 
— sheet  dipped  in  water  at  50°  to  54°  F., 
then  lightly  wrung  out,  spread  over  mat- 
tress with  oil-cloth;  then  closely  wrapped 
around  patient;  latter  rubbed  from  head 
to  foot  and  placed  with  sheet  in  woolen 
blanket  and  returned  to  bed.  Charyeux 
(Revue  de  Th6rapeutique  M(5dico-Chir., 
Oct.  1,  '95). 

In  severe  cases  rest  in  bed  for  a  few 
days  or  even  for  weeks  is  advisable,  and 
in  the  severest  cases  is  made  necessary 
by  the  violence  of  the  contortions,  which 
may  entirely  prevent  the  child  from 
walking  or  standing.  With  these  non- 
medicinal  restorative  measures  the  pa- 
tient will  usually  recover  within  a  month 
or  two,  but  in  most  cases  there  can  be 
little  doubt  that  restoration  is  hastened 
by  proper  medicinal  treatment.  The 
drugs  which  experience  has  shown  to  be 
most  useful  are  arsenic,  strychnine,  the 
zinc  salts,  silver  nitrate,  potnssium  iodide, 
and  cimicifuga. 

No  routine  treatment  can  be  followed. 
The  first  indication  is  to  remove  every- 
thing that  may  be  an  irritating  cause. 
The  patient  should  be  taken  from  school ; 
if  the  prepuce  is  too  long,  it  should  be 
cut  ofT;  if  Ihore  is  evidence  of  worms 
they  slioiild  be  got  rid  of,  etc.  The  per- 
centage of  hypermetropia,  usually  latent, 
he  believes  is  extremely  large,  perhaps 
fully  TO  per  cent.;  and  an  investigation 
for  latent  heterophoria  should  always  be 
made  with  tlie  greatest  care  and  patience. 
The  relief  of  marked  heterophoria  should 


be  finally  attained  only  by  graduated 
tenotomies  upon  the  muscles  exhibiting 
abnormal  tension  or  by  advancement  of 
the  tendons  exhibiting  defective  power. 
Prismatic  glasses  are  not  curative  and 
should  not  be  given  for  constant  use. 
Choreic  subjects  are  usually  rapidly 
cured  by  eye-treatnjent  alone;  the  eye- 
problems  encountered,  however,  are  not, 
as  a  rule,  so  complicated  and  difficult  to 
solve  as  those  of  epileptics.  Sodium  bro- 
mides employed  with  Fowler's  solution 
of  arsenic,  and,  if  there  is  a  chance  of 
malaria  being  a  factor  in  the  trouble, 
quinine  also.  Tompkins  (Amer.  Jour. 
Obst.,  Mar.,  '97). 

Sedatives  are  of  value  combined  with 
arsenic,  the  latter  being  given  in  the 
form  of  Fowler's  solution  or  as  a  solution 
of  arsenous  acid  in  doses  which  are 
rapidly  raised  to  twice  or  even  three 
times  what  is  usually  accepted  as  the 
maximum.  At  the  same  time  sodium  or 
potassium  bromide  and  antipyrine  are 
given  in  large  doses,  while  the  relation- 
ship between  rheumatism,  endocarditis, 
and  chorea  is  a  sufficient  indication  for 
the  routine  use  of  the  salicylates  in  con- 
junction with  the  other  remedies.  W. 
von  Bechterew  (Centralb.  f.  Ner\-enheilk. 
u.  Psychiatric,  Aug.,  1900). 

Study  of  1400  cases  of  chorea.  Arsenic, 
pushed  to  the  physiological  limit,  and 
then  reduced  slightly,  is  the  best  drug 
in  the  treatment,  and  antipyrine  is  sec- 
ond; exalgin,  phenacetin.  bromide,  chlo- 
ral, and  paraldehyde  produced  little 
effect.  Better  than  any  medicine  is  a 
change  of  air.  M.  Allen  Starr  ("Jacobi 
Festschrift";  Phila.  :Med.  Jour.,  May  20, 
1000). 

Several  cases  of  neuritis  which  super- 
vened after  the  cure  of  chorea  by  arsenic. 
In  these  cases  10  drops  of  liquor  arseni- 
calis  had  been  given  thrice  daily  for 
three  or  four  weeks,  by  which  time  the 
patients  had  taken  an  equivalent  of  from 
0  to  8  grains  of  arsenous  acid.  None 
of  the  cases  gave  any  warning  of  the  ad- 
vent of  the  neuritis  during  the  adminis- 
tration of  the  arsenic,  but  the  symptoms 
developed  after  an  interval  of  from  a 
week  to  a  fortnight  subsequent  to  its 
discontinuance.  No  dose  amounting  in 
the  aggregate  to  more  than  4  grains  of 


182 


CHOKEA.  TREATMENT  AND  PROPHYLAXIS. 


arsenous  acid  should  be  administered  to  a 
child  suffering  from  an  attack  of  chorea. 
Railton  (Med.  Chron.,  Feb.,  1900). 

Experiments  performed  in  1S79  by 
Chapuis  have  shown  that  arsenic  when 
combined  with  butter  appears  infinitely 
less  to.xic  than  when  given  in  solution. 
These  investigations,  personally  repeated, 
show  that  the  amount  of  butter  should 
be  invariably  fixed  to  10  grammes  what- 
ever the  quantity  of  active  principle  in- 
corporated with  it.  To  prepare  the  mixt- 
ure a  known  quantity  of  arsenous  acid 
is  taken  according  to  the  dose  to  be  ad- 
ministered. To  this  is  added  sodium 
chloride  in  such  proportion  that  0.1 
gramme  corresponds  to  0.005  of  arsenous 
acid.  This  mixture  of  sodium  chloride 
and  arsenic  is  triturated  with  10 
grammes  of  fresh  butter,  and  this 
amount  is  given  spread  on  bread:  a  form 
of  medication  which  is  extremely  pala- 
table to  children.  The  drug  must  never 
be  administered  while  fasting.  The 
whole  dose  should  be  given  at  a  time,  but 
two  doses  a  day  seem  to  be  sufficient. 
Under  this  method  of  treatment  it  is  not 
necessary  to  confine  the  patient  to  bed 
or  to  put  him  on  a  milk  diet.  A  more 
liberal  diet  gives  better  results.  L6vy 
(These  de  Lyon,  1900). 

Three  cases  of  chorea  treated  with 
sodium  cacodylate  instead  of  arsenic. 
The  former  drug  given  hypodermically, 
first  in  doses  of  Vj  grain,  then  of  Va 
grain.  The  patients  recovered  in  from 
one  to  three  weeks.  In  all  the  ordinary 
treatment  had  previously  been  tried 
without  benefit.  Lannois  (Revue  de 
ThOrap.  Med.  Chir.,  Ixviii,  No.  5,  1901). 

The  treatment  of  chorea  with  arsenic 
is  inadvisable  in  very  acute  cases  with 
coma  or  paralyses,  in  those  that  have 
been  treated  for  some  time  with  small 
doses  of  arsenic,  in  those  in  which  there 
is  reason  to  suppose  that  the  rheu- 
matic process  is  going  on  in  the  acute 
form,  and  in  eases  of  advanced  cardiac 
disease.  The  writer  gives  the  following 
principles  for  the  administration  of  ar- 
senic in  the  treatment  of  chorea;  See 
that  tlie  tongue  is  clear  before  com- 
mencing treatment,  and,  if  not,  give  a 
mild  mercurial  purge  and  a  stomachic 
mixture  for  forty-eight  hours.     Put  the 


patient  on  a  bland  and  easily  digested 
diet.  Give  the  drug  in  a  much  diluted 
form  and  in  the  same  dilution  through- 
out. Do  not  discontinue  on  the  first 
attack  of  vomiting,  which  may  be  due 
to  accidental  causes.  Increase  the  dose 
daily.  Keep  the  patient  in  bed  through- 
out the  treatment.  If  the  vomiting  per- 
sists, discontinue  the  drug  for  twenty- 
four  hours  and  then  give  the  same  dose 
as  the  last.  Examine  the  patient  very 
carefully  daily  for  any  sign  of  toxic 
action.  What  must  be  aimed  at  is  a 
form  of  shock  action  on  the  nerve-tis- 
sues, and  this  may  explain  why  long- 
continued  treatment  with  small  doses 
fails.  On  discontinuing  the  arsenic,  the 
w-riter  usually  gives  a  mixture  contain- 
ing iron  for  a  few  days.  F.  M.  Pope 
(Brit.  Med.  Jour.,  Oct.  18,  1902). 

The    cases     (86    in    number)     treated 
with  arsenic  were  of  the  shortest  dura- 
tion,   but    simple    rest    lying    down,   in 
new    surroundings    (29    cases)    without 
medicament,  proved  to  be  little  inferior 
as   a   method   of   cure.     Antip3'rine    (20 
cases)   was  less  useful,  and  bromide  (47 
cases)    and    quinine    (31    cases)    quite 
useless.    The  average  time  of  recovery 
with  the  arsenical  treatment  was  sixty- 
three    days.    Tscherno-Schwarz    (Archiv 
f.  Kinderli.,  vol.  xxxv,  p.  454,  1903). 
It  is  always  to  be  kept  in  mind  that 
chorea  is  a  symptom,  in  many  instances, 
of  some  general  bodily  enfeeblement  or 
disease;  a  thorough  and  searching  phys- 
ical  examination   should   invariably  be 
made. 

Chorea  is  usually  started  by  some  re- 
flex irritation,  such  as  eye-strain,  nasal 
irritation,  tight  prepuce,  a  bound-down 
clitoris,  or  lumbricoid  worms;  and  sec- 
ondary attacks  may  not  always  be  true 
chorea.  TIic  patients  can  be  divided  into 
two  classes:  those  that  tend  to  get  well 
under  almost  any,  or  even  without  treat- 
ment, and  those  who  fail  to  obtain  relief 
from  medicine.  In  the  latter  the  percent- 
age of  hypermetropia,  usiuilly  latent,  is 
extremely  large,  apparently  about  70  per 
cent.;  and  an  investigation  of  latent 
heterophoria  should  always  be  made,  in 
choreic  subjects,  with  the  greatest  caro 
and    patience.     Finally,    the   spasmodic 


CUOREA.  TREATMENT  AND  PROPHYLAXIS. 


183 


movements  which  accompany  and  indi- 
cate organic  lesions  of  tlie  brain — as,  for 
example,  tliose  of  leptomeningitis — exist 
in  but  a  small  proportion  of  choreic  sub- 
jects, and  are  usually  associated  with 
other  evidences  of  disease.  Tompkins 
(Amer.  Jour.  Obst.,  Mar.,  '97). 

Especial  attention  should  be  given  the 
intestinal  tract  and  stomach,  renal  dis- 
order, or  any  state  of  autogenous  poison- 
ing, anremia,  malarial  poisoning,  the 
presence  of  intestinal  parasites,  etc. 

The  use  of  morphia,  chloral,  chloro- 
form or  other  sedative  for  the  suppres- 
sion of  the  muscular  movements  is  of 
questionable  propriety  in  any  case,  and 
will  usually  prove  injurious. 

Antipyrine  in  large  doses:  4,  8,  or  15 
grains,  according  to  age,  repeated  2,  3, 
or  5  times  a  day;  may  be  continued 
weeks  without  ill  effect.  Comby  (La 
France  Mfd.  et  Paris  MCd.,  Sept.  6,  '95). 

Antipyrine  had  a  beneficial  effect  in 
40  out  of  60  cases,  but  in  three-fifths  of 
these  cases  the  affection  recurred.  Wliere 
the  drug  failed  the  failure  was  due  to 
intolerance  or  cutaneous  eruption,  but 
in  a  few  cases  it  seemed  to  have  no  efTect. 
It  wa3  found  necessary  to  give  largo 
doses;  doses  from  '/j  to  1 'A  drachms 
were  well  tolerated  for  some  weeks.  Le- 
roux  (Revue  Mens,  des  Mai.  de  I'Enfance, 
June,  '91). 

Severe  typical  case  of  Sydenham's 
chorea  rapidly  cured  with  camphor  bro- 
mide, increasing  from  '/j  to  2Vj  drachms 
a  day  during  twelve  days,  again  decreas- 
ing to  'A  during  next  fifteen  days. 
Bourneville  and  Katz  (Progr&s  Med., 
July  16, '98). 

Satisfactory  results  from  antipyrine 
given  according  to  Eskridge's  method. 
The  drug  is  given  in  increasing  doses, 
beginning  with  1  grain  for  each  year  of 
the  child's  age,  and  increasing  1  grain 
each  day.  In  the  mildest  cases  the  child 
is  allowed  to  sit  up  a  part  of  a  day,  and 
the  antipyrine  is  only  given  in  the  even- 
ing, but  in  severe  cases  absolute  rest  in 
bed  is  necessary,  the  dose  of  antipyrine 
being  given  three  times  a  day.    The  drug 


is  stopped  as  soon  as  the  choreic  move- 
ments cease  or  greatly  diminish.  Fow- 
ler's solution  and  iron  are  given  until 
two  or  three  weeks  after  the  cure  ap- 
pears to  be  complete.  In  giving  such 
doses  of  antipyrine  (20  grains  three  times 
a  day  to  a  child  8  years  old)  the  child 
must  be  kept  in  bed  and  carefully 
watched;  should  there  be  heart  disease 
or  any  fever,  it  is  not  given.  Rapid 
cures  were  obtained  in  nineteen  cases  so 
treated.  S.  D.  Hopkins  (Philadelphia 
Med.  Jour.,  Aug.   19,  '99). 

Physostigma  (Calabar  bean)  used  in 
two  extremely  violent  cases  of  chorea. 
Results  were  better  than  those  usually 
obtained  by  the  treatment  with  arsenic. 
Extract  of  physostigma  was  given  in 
doses  of  Vio  grain,  three  times  a  day. 
J.  W.  Russell  (Birmingham  Med.  Re- 
view, Sept.,  1900). 

Very  many  of  these  eases  are  habit 
cases,  induced  by  some  trivial  local 
source  of  irritation  or  reflex  influence 
not  of  central  origin.  In  such,  static 
electricity  plays  a  double  rOle,  and  is 
uniformly  successful  if  applied  early. 
(1)  It  lessens  the  irritabilit.v  and  (2) 
acts  as  a  powerful  suggestive  influence 
when  systematically  employed. 

Most  cases  of  central  origin  are  not 
due  to  any  traceable  organic  defect,  but 
are  induced  by  functional  derangement. 
Such  are  capable  of  being  cured  if  not 
of  too  long  standing.  For  treatment,  a 
metal  electrode  covering  the  affected 
muscles  is  applied  and  held  in  position 
with  the  hand,  and  the  wave-current  is 
employed  with  as  long  a  spark-gap  as 
can  be  used  without  causing  painful 
muscular  contractions.  Sparks  to  the 
region  will  also  render  the  results  more 
effective  in  some  cases.  If  the  condition 
is  suspected  to  be  of  central  origin,  a 
large  electrode  to  the  back  or  abdomen 
should  be  used,  as  in  epilepsy,  for  an 
additional  fifteen  minutes  for  its  general 
effect.  Under  this  rfgimc  there  are  few 
cases  of  not  more  than  two  years'  stand- 
ing that  will  not  yield.  W.  B.  Snow 
(Journal  of  Electrotherapeutics,  Dec, 
1901). 

After  recovery  from   chorea   especial 
care  should  be  exercised  in  the  education 


184 


CHOREA.    ANOMALOUS  VARIETIES. 


and  bringing  up  of  the  child.  A  display 
of  good  judgment  and  the  intelligent  di- 
rection of  conduct  and  development  will 
be  well  repaid  in  increased  stability  and 
safety  from  relapse  or  from  the  subse- 
quent occurrence  of  some  otJier  and  more 
serious  neurosis. 

The  treatment  of  chorea  insaniens  is 
practically  the  same  as  that  of  an  out- 
burst of  acute  mania.  Active  measures 
— eliminants  and  nerve-sedatives — are 
indicated. 

Anomalous  Varieties  of  Chorea. 

The  otlier  conditions  described  under 
the  name  of  chorea  are: — 

Endemic  chorea,  or  epidemic  chorea, 
a  form  of  acute  chorea  with  hysterical 
symptoms  which  develops  in  a  number 
of  persons  at  or  about  the  same  time  in 
the  same  school  or  community.  Sug- 
gestion plays  an  important  part  in  its 
etiology. 

Hysterical  chorea:  Closely  allied  to 
the  above,  but  with  the  characteristic 
symptoms  of  hysteria  superadded.  The 
so-called  "chorea  major"  is  a  purely  hys- 
terical phenomenon,  and  is  not  a  chorea 
at  all. 

Electrical  chorea  is  the  name  given  to 
certain  forms  of  acute  chorea  in  which 
the  movements  are  sudden  and  light- 
ning-like in  onset,  and  also  to  a  state  in 
which  sudden  rhythmical  muscular  con- 
tractions occur,  simulating  a  "lie  co- 
ordine."  The  term  is  loosely  employed, 
and  is  used  in  a  different  sense  by  differ- 
ent authors. 

Procursive  chorea,  or  "chorea  festi- 
nans,"  is  a  form  of  chorea  with  hys- 
terical accompaniments  in  which  rhyth- 
mical dancing  and  procursive  movements 
are  prominent,  vertigo  being  often  pres- 
ent at  the  same  time. 

Saltatory  spasm  is  a  choreoid  affection 
sometimes  occurring  in  epidemics,  and 
characterized  by  peculiar  jumping  and 


dancing  movements,  which  are  executed 
when  the  patient  is  startled  in  any  way. 
It  is  closely  related  to  the  forms  of  mus- 
cular clonic  spasm  affecting  a  few  or 
many  groups  of  muscles  of  the  body  to 
which  the  name  "tic  convulsif"  is  given. 
It  is  also  spoken  of  as  "lata."  It  occurs 
in  degenerates  of  hysterical  tendencies, 
is  often  accompanied  by  the  uncon- 
scious and  involuntary  repetition  of 
words  and  phrases  and  actions  seen  or 
heard,  and  by  the  involuntary  repetition 
of  obscure  words. 

Oscillatory  or  nodding  spasm,  spasm 
nutans,  is  characterized  by  rhythmical 
wagging  or  nodding  movements  of  the 
head  occurring  in  paroxysms  or  continu- 
ing for  hours,  or  even  during  the  entire 
time  the  patient  is  awake.  It  occurs  in 
extreme  degenerates,  and  may  be  com- 
plicated with  epilepsy  or  other  neurosis, 
or  may  accompany  a  hemiplegia  or  other 
secondary  degeneration.  It  shades  im- 
perceptibly into  "habit  chorea." 

Tic  co-ordine,  or  habit  chorea,  consists 
in  the  involuntary  occurrence  of  tricks  of 
speech  or  gesture — a  twist  of  the  head, 
shrug  of  the  shoulder,  etc.  It  is  some- 
times a  result  of  an  early  attack  of  acute 
chorea,  but  occurs  also  as  a  primary 
affection,  and  may  be  inherited. 

Post-hemiplegic  chorea  is  a  name  given 
to  the  irregular  rhythmical  or  arhylh- 
mical  jerky  movements  sometimes  seen 
in  hemiplegic  limbs.  Similar  move- 
ments may  occur  as  a  result  of  infantile 
cerebral  palsies. 

Chronic  adult  chorea  is  characterized 
by  choreic  movements  associated  with 
spastic  symptoms  and  progressive  mental 
deterioration.  There  is  always  marked 
degeneration  in  cortical  cells  and  in 
pyramidal  tracts.  If  there  is  a  history  of 
chorea  in  ancestry  this  "chronic  adult 
chorea"  is  called  "Huntington's"  or 
"hereditary  chorea."    The  affection  was 


CHROMIC  ACID. 


185 


described  fifty  years  ago  in  America,  but 
has  obtained  general  recognition  only 
since  Huntington  called  attention  to  it 
in  1872.  In  typical  cases  the  disease  de- 
velops insidiously,  slowly  progresses,  and 
terminates  in  marked  spastic  paralysis 
with  advanced  dementia,  or  in  death.  It 
is  closely  related,  in  etiology,  pathology, 
and  clinical  features,  to  general  paresis, 
into  which  it  probably  shades  by  insen- 
sible degrees. 

Careful  pathological  study  made  of 
case  of  Huntington's  chorea.  Investiga- 
tion of  family  history  showed  that  nine 
members,  beginning  with  patient's  grand- 
father, had  been  affected.  The  changes 
consisted  in  a  chronic  parenchymatous 
degeneration  of  the  cortex,  with  consecu- 
tive changes  in  the  interstices  and  vascu- 
lar system.  The  belief  expressed  that  the 
cells  are  originally  properly  formed,  but 
that  they  are  not  endowed  with  their 
normal  longevity. 

In  Huntington's  chorea,  drugs,  if  given 
at  all,  must  be  administered  in  the  largest 
possible,  almost  toxic,  doses,  for  a  long 
period  of  time.  The  marriage  of  persons 
with  a  heritage  of  Huntington's  chorea 
should  be  discouraged.  Joseph  Collins 
(Amer.  Jour.  Med.  Sciences,  Sept.,  '98). 
Case  in  which  the  essential  lesion  con- 
sisted in  the  diminution  in  size  of  nerv- 
ous elements  generally,  an  increase  in 
pigment  content  of  the  nerve-cells,  espe- 
cially in  those  of  the  cerebellum;  an 
overgrowth  of  neuroglia  tissue,  —  the 
relation  of  which  to  the  nervous  ele- 
ments seems  to  be  passive  and  possibly 
accounted  for  by  the  so-called  "tissue 
tension," — a  shrinkage  of  the  cells  in  the 
dorsal  root  ganglia  with  the  analogous 
proliferation  of  the  endothelial  cells  of 
their  capsules,  a  pigmentary  degenera- 
tion of  the  neuroglia,  and  a  degeneration 
of  the  white  matter  about  the  periphery 
of  the  cord.  O.  Y.  Rusk  (Amer.  Jour, 
of  Insanity,  July,  1902). 
These  forms  of  choreic  movements 
with  degenerations  in  brain  and  cord  are, 
of  course,  incurable. 

It  will  be  seen  that  the  term  chorea 
has    been    applied    to    numerous    and 


widely-different  affections,  insuring  some 
confusion,  as  previously  remarked.  It 
is  unfortunate  that  the  name  of  "chorea" 
cannot  be  entirely  restricted  to  mean  the 
acute  or  Sydenham's  chorea,  since  this 
is  a  tolerably-well-defined  group  of  clini- 
cal symptoms,  with  a  definite  course  and 
character.  The  other  varieties  of  chorea 
are  symptoms  of  hysteria  and  extreme 
degeneracy  or  of  chronic  degeneration  in 
motor  cells  and  tracts,  and  should  pref- 
erably be  relegated  to  their  proper  noso- 
logical place. 

E.  D.  BONDURANT, 

Mobile. 

CHOROID.  See  Iris,  Ciliary  Body, 
AND  Choroid. 

CHEOMIC  ACID.— This  is  an  anhy- 
dride, found  as  brilliant,  crimson-red, 
acicular,  deliquescent  crystals  that  are 
most  freely  soluble  in  water.  It  is  pre- 
pared by  mixing  a  solution  of  potassium 
bichromate  with  sulphuric  acid,  reject- 
ing the  crystals  of  acid  sulphate  of  potas- 
sium which  crystallize  cut,  heating  the 
liquor,  and  adding  more  sulphuric  acid, 
when  the  chromic  acid  is  formed  by 
crystallization.  It  is  also  soluble  in 
ether  that  is  free  from  alcohol  and  water. 
It  is  decomposed  by  most  acids — lactic, 
sulphurous,  hydrosulphuric,  hydro- 
chloric, arsenous,  etc.;  by  glycerin;  and 
is  likely  to  cause  explosion  if  mixed  with 
the  latter  or  with  alcohol. 

Preparations  and  Doses.  —  Chromic 
anhydride  (chromic  acid),  external  use 
only. 

Chromic-acid  liquor  (1  part  to  3  of 
distilled  water),  external  use  only. 

Physiological  Action. — Chromic  acid 
possesses  the  power  of  killing  all  low 
organisms,  oxidizing  organic  matter, 
coagulating  albumin,  and  destroying  the 
tissues  with  which  it  comes  in  contact. 
It  is  thus  antiseptic,  disinfectant,  and 


1S6 


CHKOiUC  ACID. 


CHKYSAKOBIN. 


powerfully  caustic.  Made  into  a  paste 
with  water,  its  action  is  exceedingly  slow 
and  gradual,  but  deeply  penetrating;  in 
saturated  solution  it  is  less  penetrating 
and  slower  in  action.  By  employing  a 
solution  more  or  less  dilute,  the  action 
may  be  graduated  according  to  the  ef- 
fects desired.  Death  has  resulted  from 
absorption  when  it  has  been  applied  too 
freely.  Its  local  effects  are,  for  the  most 
part,  antagonized  by  bland  neutral  fats, 
applied  in  excess.  The  toxic  effects  are 
similar  to  those  of  potassium  bichro- 
mate. 

Therapeutics.  —  As  an  Antiseptic 
AND  Disinfectant. — Two  drachms  of 
chromic  anhydride  added  to  4  or  5 
quarts  of  water  gives  an  inexpensive, 
but  efficient,  antiseptic  and  disinfecting 
lotion  for  leucorrhceas,  ozasnas,  hyperi- 
drosis,  putrid  sores,  etc.;  a  lotion  of  10 
grains  to  the  ounce  has  a  decided  effect 
upon  syphilitic,  gouty,  and  kindred 
maladies  of  tongue  and  throat.  As  a 
local  application  to  cancerous  and  other 
ulcerations,  it  is  preferable  to  all  other 
caustics,  since  the  pain  attendant  on  its 
application  is  trifling;  but  it  must  be 
used  cautiously  and  discriminatingly. 

Morbid  Growths.  —  A  concentrated 
solution  is  useful  in  removing  syphilitic 
condylomata  and  warts  and  other  mor- 
bid growths  from  the  genital  region.  It 
has  been  applied  to  external  and  bleed- 
ing ha}morrhoids,  to  fungus  hmmatodes, 
onychia  maligna,  and  onychia  parasitica 
with  great  benefit.  Warts  quickly  yield 
to  the  application  of  chromic-acid  crys- 
tals, after  the  surface  of  the  growth  has 
been  slightly  moistened. 

Trachoma. — Some  years  ago  a  French 
oculist  (Hairion)  employed,  with  advan- 
tage, a  solution  of  equal  parts  of  acid  in 
distilled  water,  applied  with  a  camel's- 
hair  pencil  to  obstinate  granular  oph- 
thalmia.   The  applications  were  made  at 


intervals  of  four,  six,  and  eight  days, 
and,  although  it  was  never  very  painful 
or  followed  by  any  great  amount  of  re- 
action, it  admits  of  great  doubt  how  far 
so  deeply  a  penetrating  caustic  can,  with 
safet}',  be  applied  to  so  delicate  an  organ 
on  the  eye. 

Diseases  of  the  Air-passages. — 
But  the  greatest  availability  appears  to 
be  in  treating  diseases  of  the  throat, 
upper  pharynx,  and  nose.  Owing  to  its 
hygroscopic  character,  no  agent  is  so 
effective  when  applied  to  nasal  polypi, 
and  it  is  also  highly  recommended  in 
hypertrophic  rhinitis.  In  either  case  the 
most  convenient  method  is  to  heat  the 
tip  of  an  ordinary  probe  and  touch  it  to 
one  of  the  acicular  crystals  of  acid; 
enough  adheres  for  two  applications,  but 
care  must  be  taken  not  to  overheat  the 
instrument,  lest  decomposition  of  the 
chromic  anhydride  should  occur,  and  an 
insoluble  compound  be  formed. 

CHRYSAROBIN.  —  This  drug,  also 
known  as  "Goa  powder,"  "Araroba 
powder,"  "Po  de  Bahia,"  and  also  (im- 
properly) as  "chrysophanic  acid,"  is  the 
metamorphosed  heart-wood  of  the  An- 
dira  araroha:  a  leguminous  tree  indig- 
enous to  Brazil.  It  is  a  brownish -yellow 
crystalline  powder,  permanent  in  the  air, 
tasteless,  odorless,  almost  insoluble  in 
water,  slightly  so  in  alcohol,  completely 
in  ether,  containing  a  variable  amount — 
70  to  80  per  cent. — of  chrysophan, 
which  latter,  by  oxidation,  is  readily 
transformed  into  chrysophanic  acid. 

Chrysophanic  acid  is  a  neutral  sub- 
stance, identical  with  rhein,  the  active 
principle  of  rhubarb.  It  is  commonly 
found  as  a  granular,  orange-yellow 
powder,  but  sometimes  takes  the  form 
of  bright,  shining-yellow  needles:  a 
transformation  that  is  effected  by  subli- 
mation.   It  is  odorless,  acrid,  soluble  in 


CHRYSAROBIN. 


187 


alkaline  waters,  oils  and  fats,  chloro- 
form, petroleum  spirit,  and  glycerin;  but 
is  insoluble  in  water,  alcohol,  and  ether. 

Preparations  and  Doses. — CJhrysaro- 
bin,  Vs  to  5  grains. 

Chrysophanic  acid,  Vg  to  V2  grain; 
as  an  emetic  and  purge,  8  to  20  grains. 

Chrysarobin  ointment  (acid,  chry- 
sophanic, 1;   benzoated  lard,  24). 

Compound  chrysarobin  ointment 
(chrysarobin,  5;  salicylic  acid,  2;  ich- 
thyol,  5;    vaselin,  88). 

Chrysarobin  pigment  (acid,  chryso- 
phanic, 1;  solution  of  gutta-percha,  9). 

Araroba  ointment  (chrysarobin,  6; 
glacial  acetic  acid,  1;  lard,  14). 

Bismuth  chrysophanate,  external  use 
as  an  antiseptic  only. 

Zinc  chrysophanate,  an  antiseptic 
dusting-powder. 

Physiological  Action. — In  general  the 
action  of  chrysarobin  and  chrysophanic 
acid,  when  given  internally,  is  not  un- 
derstood, but  Brunton  and  Delepine  be- 
lieve the  latter  to  be  an  hepatic  stimu- 
lant, and  that  it,  at  the  same  time,  pro- 
duces a  marked  increase  in  the  glycogen 
of  the  liver.  It  may  be  added,  however, 
that  chrysarobin  is  nn  active  irritant 
poison,  and  even  in  minute  doses  induces 
gastro-intestinal  disturbances,  such  as 
vomiting  and  purging.  There  is  noth- 
ing to  the  credit  of  either  drug  that 
should  lead  to  its  use  as  an  internal 
remedy. 

Externally,  chrysarobin  is  an  irritant 
to  the  skin,  staining  it  yellow;  and,  ap- 
plied in  excess,  produces  irritation  and 
inflammation,  accompanied  by  swelling, 
itching,  pain,  heat,  and  sometimes  a 
papular  eruption;  and  the  action  is  not 
always  limited  to  the  part  to  which  it  is 
applied,  but  extends  to  the  healthy  skin 
in  the  vicinity. 

Chrysophanic  acid  does  not  cause  dis- 
coloration, but  it  is  much  less  active 


than  chrysarobin,  and  does  not,  in  any 
sense,  represent  the  true  principles  of 
the  latter. 

Therapeutics.  —  Skix  Diseases. — 
There  is  no  doubt  that  chrysarobin  is  a 
remedy  of  value  in  parasitic  skin  dis- 
eases, and  especially  in  psoriasis,  but 
chrysophanic  acid  is  far  from  upholding 
the  repute  of  its  derivative. 

Chrysophanic  acid  does  not  stain  like 
chrysarobin,  and  is  scarcely  at  all  irri- 
tating;    but    comparative    e.xperiments 
made  .with   the  two   substances  in   the 
treatment  of  psoriasis  lead  to  the  con- 
clusion that  the  former  is  not  an  effi- 
cient  substitute   for  the  latter   in   the 
treatment   of  this   disease.     Walter   G. 
Smith  (Brit.  Jour.  Derm.,  July,  '96). 
Though  at  various  times  recommended 
in  the  management  of  acne  and  eczemas, 
chrysarobin  is  seldom  of  value. 

CHYLURIA. 

Definition. — A  peculiar  condition  of 
the  urine  in  which  it  presents  a  milky, 
or  chylous,  appearance  and  contains  the 
constituents  of  chyle,  especially  fat  and 
albumin. 

Varieties. — Two  varieties  of  chyluria 
have  been  observed:  (1)  the  tropical 
chyluria,  which  is  of  parasitic  origin; 
(2)  the  non-tropical  chyluria,  the  cause 
of  which  is  unknown. 

Symptoms. — Chyluria  presents  an  ex- 
tremely-varied clinical  history,  and  the 
descriptions  given  of  cases  are  most  di- 
verse. Its  course  is  marked  by  an  irregu- 
larity and  capriciousness  which  cannot 
be  explained.  The  only  constant  symp- 
tom is  the  presence  of  so-called  chylous 
urine.  This  fluid  usually  presents  a 
peculiar  whitish,  opaque,  milky  appear- 
ance; sometimes  the  color  is  not  whitish, 
but  pink  from  the  presence  of  blood. 
Occasionally  the  blood  is  not  intimately 
mixed  with  the  urine  and  very  soon 
forms  an  adherent  coagulum  at  the  bot- 
tom of  the  vessel.    In  many  cases,  the 


188 


CHYLURIA.     SYMPTOMS. 


urine,  after  some  standing,  will  form  a 
superficial  stratum  resembling  cream  or 
llanc-mange.  The  odor  of  the  urine  is 
ordinarily  acid,  rarely  urinous;  its  re- 
action acid  or  neutral,  rarely  alkaline. 
Chylous  urine  ordinarily  decomposes 
speedily  and  will  then  smell  of  sulphu- 
reted  hydrogen.  Sometimes  it  has  been 
observed  that  chylous  urine  could  be 
kept  for  months  without  fermenting. 
The  specific  gravity  of  the  urine  as  well 
as  its  appearance  varies  greatly  in  the 
same  person  at  different  times,  even  at 
different  periods  of  the  day.  The  urine 
may,  in  some  cases,  contain  coagula  be- 
fore evacuation,  which  may  cause  local 
disturbance  and  pain  while  it  is  being 
passed.  When  blood-serum  is  added  to 
chylous  urine,  large  coagula  will  ordi- 
narily form. 

Microscopical  examination  of  the  urine 
shows  that  it  contains  fat  in  molecular 
form,  but  milk-globules  or  large  drops 
of  fat  are  not  seen;  the  urine  further 
contains  leucocytes  and  blood-corpuscles, 
both  white  and  red.  In  some  cases  crys- 
tals of  uric  acid  have  been  observed, 
when  the  reaction  of  the  urine  is  alka- 
line, the  characteristic  crystals  of  phos- 
phate of  ammonia — magnesia — are  ob- 
served. Frerichs  relates  that  in  one 
case  he  found  the  urine  to  contain  a 
multitude  of  ripe  and  unripe  sperma- 
tozoa. In  the  tropical  variety  of  chy- 
luria,  Lewis,  in  1870,  and  after  him 
many  other  investigators,  found  the  em- 
bryos of  Filaria  sanguinis  in  the  urine. 

By  shaking  the  urine  with  ether,  the 
fat  molecules  are  dissolved  and  the  urine 
clears  up,  completely  or  partially.  Be- 
sides, the  ordinary  fat-cholesterin  and 
lecithin  have  also  licen  found. 

Chylous  urine  always  contains  albu- 
min, generally  in  the  form  of  serum- 
albumin;  but  globulin,  albumose,  and 
pepton  may  likewise  be  present.    Casein 


has  never  been  observed;  sugar  is  not 
ordinarily  contained  in  chylous  urine, 
but  Pavy  and  Habershon  are  said  to  have 
found  it  in  one  case. 

Quantitative  estimation  of  the  con- 
tents of  chylous  urine  have  been  made 
in  great  number;  the  amount  of  fat 
varies  from  0.028  to  3.3  per  cent.,  while 
the  albumin  was  found  in  a  quantity  of 
0.12  to  2.7  per  cent.  As  may  be  seen, 
their  relative  proportion  varies  much. 

The  discharge  of  chylous  urine  usually 
occurs  very  suddenly;  it  may  be  con- 
stant, but  more  frequently  is  intermit- 
tent. The  chyluria  may  cease  for 
months  and  years  and  reappear  without 
appreciable  cause,  even  if  the  patient  has 
made  a  complete  change  of  climate.  The 
urine  is,  in  many  cases,  chylous  only  in 
the  early  hours  of  the  day,  or  presents, 
at  that  time,  a  much  larger  quantity  of 
chyle  than  at  other  periods  of  the  day. 
This  intermittence  has  been  observed  as 
well  in  the  tropical  as  in  the  non-tropical 
varieties  of  chyluria.  In  some  instances 
the  position  of  the  body — recumbent  or 
erect — is  found  to  bear  influence. 

Case  in  a  man,  57  years  old,  who  had 
been  in  Florida  for  awhile.  He  can  bring 
on  a  chyluria  by  lying  down  an  liour, 
and  more  readily  if  he  lies  on  the  back 
than  on  the  side.  The  Filaria  sanguinis 
found  by  Dr.  Ernst  in  his  blood.  Vickery 
(Boston  Med.  and  Surg.  Jour.,  Dec.  16, 
'97). 

1.  Chylous  urine  may  result  from  a 
fialuloiis  communication  between  tha 
lymphatic  and  urogenital  system.  2.  It 
may  also  be  due  to  lipa^mia,  the  kidneys 
secreting  a  fatty  urine.  .S.  Tropical  chy- 
luria is  always  parasitic  and  due  to  the 
Filaria  sanguinis  hnminis  or  Distoma 
luvmntiihium  ;  non-tropical  chyluria  not 
d('[iciidcnt  on  lipirmia  niiiy  be  caused  by 
the  KiiKtrongiilas  gigas  and  possibly  also 
by  Tirnia  nana.  4.  The  pathology  of  the 
non-parasitic  types  is  not  known,  but 
these  may  depend  on  tumors,  peritoneal 
lidhosionB,  etc.     5.   Certain   peculiarities 


CHYLURIA.    DIAGNOSIS.    ETIOLOGY  AND  PATHOLOGY. 


189 


of  the  nontropical  disease — such  as  the 
absence   of  sugar   in   the   urine,  the   oc- 
currence of  periodical   attacks,  and  the 
varying  composition  of  the  urine  during 
the   twenty-four    hours— require    furtlier 
explanation.       W.     K.     Predtetschenaky 
(Zeits.  f.  klin.  Med.,  B.  40,  H.  1,  1900). 
In  most  cases  symptoms  referable  to 
the  urinary  organs  are  noticed,  such  as 
pains  in  the  lumbar  region,  along  the 
urethra,  etc.    Occasionally  the  urine  co- 
agulates in  the  bladder,  causing  pain  and 
difficulty  during  micturition. 

Persons  suffering  from  chyluria  may 
enjoy  good  health,  but  generally  there  is 
weakness,  wasting,  with  mental  depres- 
sion. Tropical  chyluria  is  often  accom- 
panied by  fever  and  diarrhcea. 

Chyluria  follows  a  very  chronic  course. 
Diagnosis.  —  Chyluria  may  resemble 
pyuria  and  lipuria;  it  can  be  distin- 
guished from  both  by  microscopical  ex- 
amination; in  pyuria  the  urine  contains 
innumerable  pus-corpuscles;  in  lipuria 
the  fat  is  not  present  in  molecular  form, 
but  in  large  drops  or  in  fine  needles  and 
crystals. 

Etiology  and  Pathology. — The  tropi- 
cal, or  parasitical,  variety  of  chyluria  is 
the  best  known,  and  its  etiology  has  been 
elucidated  by  dilTerent  authors.  It  has 
been  observed  in  the  United  States, 
China,  Japan,  Siam,  the  Isle  of  France, 
Brazil,  the  East  Indies,  Egypt,  Eeunion, 
Mauritius,  Australasia,  and  recently  also 
in  Europe  in  persons  who  never  had 
lived  in  tropical  regions.  Tropical  chy- 
luria is  caused  by  the  presence  in  the 
blood  of  the  embryos  of  Filaria  san- 
guinis liominis:  a  nematoid  worm. 

These  embryos  were  first  found  in  the 
urine  by  Wucherer,  of  Bahia,  and  later 
also  observed  in  the  blood  by  Lewis. 
Their  natural  history  has  been  elucidated 
by  many  observers,  especially  by  Manson. 
The  adult  filaria  has  a  length  of  from 
30  to  40  millimetres  and  is  filiform:  the 


embryo  measures  0.0075  millimetre  in 
diameter  and  0.34  millimetre  in  length. 
Manson  found  that  the  parent  filaria 
live  in  the  lymphatics  on  the  distal  end 
of  the  glands;  they  are  oviparous  and 
their  eggs  are  arrested  in  the  glands  and 
hatched  there.  The  free  embryos  then 
pass  along  the  lymphatic  vessels  and  en- 
ter the  circulation.  Eesting  in  some 
organ  during  the  day,  they  circulate  with 
the  blood  during  the  night,  or,  as  Mac- 
kenzie has  shown,  they  rest  during  the 
sleep  of  their  host,  whether  it  be  night 
or  not. 

Manson  describes  four  varieties  of 
filaria: — 

Filaria  nocturna,  which  can  be  de- 
tected in  the  blood  only  at  night. 

Filaria  diuma,  which  is  found  in  the 
blood  during  the  day  only. 

Filaria  perstans,  which  is  always  pres- 
ent in  the  capillaries. 

Filaria  Demarquay,  not  half  the  size 
of  the  ordinary  filaria. 

Filaria3  diurna  and  perstans  seem  to  be 
confined  to  the  western  part  of  Africa, 
while  filaria  nocturna  is  always  present 
in  tropical  countries  and  is  endemic  in 
some  parts  of  the  United  States  of  Amer- 
ica. 

Study  of  the  blood  of  about  sixty 
negroes  belonging  to  the  different  tribes 
of  the  Congo  States.  Embryos  of  filaria 
in  the  blood  of  the  majority  of  them 
found.  Filaria  were  also  found  in  the 
blood  of  a  negro  from  the  Congo  who 
had  been  living  in  Belgium  for  six  years. 
Firket  (Annual  of  the  Univ.  Med.  Sci., 
vol.  i,  D-29,  '96). 

It  has  not  j'et  been  proved  in  what 
manner  the  embryos  of  the  filaria  give 
rise  to  chyluria,  but  it  is  commonly  be- 
lieved that  the  parasites  obstruct  the 
lymphatics  and  cause  their  delicate  walls 
to  rupture,  or  that  they  perforate  the 
walls  of  the  chyliferous  vessels  and  bring 
about  abdominal  communications. 


190 


CHYLUiUA.    PROGNOSIS.    TREATMENT. 


It  has  already  been  mentioned  that 
chyluria  presents  an  extremely  varied 
clinical  history  and  may  be  accompanied 
by  divers  other  symptoms,  such  as  chy- 
lurious  discharges  from  various  parts  of 
the  body,  with  elephantiasis,  lymphan- 
gieetasis,  etc. 

The  diversity  of  the  clinical  manifesta- 
tions may,  perhaps,  find  its  explanation 
by  the  fact  that  it  is  not  always  caused 
by  the  same  species  of  filaria. 

The  non-tropical  variety  of  chyluria 
is  not  of  parasitical  nature,  and  its  origin 
is,  as  yet,  quite  obscure;  it  occurs  even 
in  cold  climates,  but  is  a  very  rare  dis- 
ease. 

Hansen's  observations  seemed  to  show 
that  the  embryos  were  taken  along  with 
the  blood  in  the  stomach  of  a  certain 
form  of  mosquito  in  which  they  undergo 
developmental  changes.  After  some  days 
the  mosquito  discharges  its  eggs  in  the 
water  of  some  pool  and  the  filaria  there 
becomes  free,  and  by  this  medium  the 
animals  are  conveyed  to  the  human  sys- 
tem, through  drinking  the  water. 

Mosquitoes  seem  to  be  the  active 
agents  by  which  the  disease  is  propa- 
gated. The  mosquito  bites  a  man  or  an 
animal  affected  with  the  filarial  disease. 
The  filaria  curls  itself  around  the  pro- 
boscis of  the  mosquito,  is  sucked  into 
the  stomach  of  the  insect,  passes  into  its 
tissues,  grows,  and  develops  there.  When 
the  mosquito  dies  the  worm  is  set  free, 
and,  getting  into  drinking-water,  is 
again  introduced  into  the  human  subject 
through  the  stomach  and  alimentary 
canal.  Byrom  Bramwell  (Brit.  Med. 
Jour.,  July  31,  '97). 

In  some  cases  very  small  drops  of  fat 
have  been  observed  to  circulate  with  the 
blood  and  to  be  discharged  through  the 
kidneys;  in  some  instances  the  authors 
favor  the  belief  that  the  urine  is  secreted 
in  its  normal  state,  but  that  the  fat  is 
added  during  its  passage  through  the 
ureters  and  the  bladder. 


The  dependence  of  the  chylous  change 
in  the  urine  upon  the  introduction  of 
fat  into  the  intestinal  canal  is  proven 
by  the  disappearance  of  tlie  fat  in  the 
urine  under  starvation;  by  the  appear- 
ance of  fat-free  urine  under  a  diet  very 
poor  in  fat;  by  the  excretion  of  specific 
fats,  such  as  olive  oil  colored  with 
Sudan  red,  erucin,  lipanin,  by  tlie  urine 
following  their  introduction  into  the 
gastio-intestinal  tract;  and  by  the  cir- 
cumstance that  fat  which  is  with  dif- 
ficulty absorbed  appears  in  the  meas- 
ure of  its  absorbabilit}' ;  the  lack  of  re- 
lation between  the  excretion  of  fat  in 
the  urine  and  its  introduction  by  other 
methods,  as,  for  instance,  by  subcu- 
taneous introduction  of  colored  fat; 
the  early  apfjearance  of  alimentary 
glycosuria,  caused,  probably,  bj'  the  in- 
creased quantity  of  sugar  in  the  chyle, 
resulting  from  the  great  amount  in  the 
intestinal  canal;  the  appearance  of 
chiefly  mononuclear  leucocytes  in  the 
chylous  urine.  Franz  and  von  Stejskal 
(Zeit.  f.  Heilk.,  Bd.  xxiii,  ht.  11,  Abth. 
F.,  ht.  4,  p.  441,  1902). 
Prognosis. — Chyluria  is  ordinarily  a 
disease  of  long  duration.  Sometimes  the 
patients  recover  spontaneously;  in  other 
cases  it  leads  to  anemia  and  severe  diar- 
rhoea and  the  patient  dies  from  exhaus- 
tion. 

Treatment. — Medicine  seems  to  have 
but  little  influence  on  chyluria.  Eest, 
good  nutritious  diet  which  is  not  too 
exclusively  animal,  the  use  of  pure  water 
for  drinking  purposes,  iron,  and  quinine 
have  been  recommended,  as  well  as  large 
doses  of  iodide  of  potassium.  Against 
the  parasitic  chyluria  anthelmintics  have 
been  tried,  as  methylene-blue  (Austin 
Flint,  Annual  '96,  vol.  i,  D-80)  and  thy- 
mol (Crombie,  Annual,  '96,  vol.  i,  D- 
81).  In  the  tropics  a  plant — pcntaphyl- 
lum — is  much  relied  upon;  mangrove- 
bark  is  considerably  used  in  Guiana. 

Case  of  filarial  chyluria  in  wliom,  other 
treatments  having  failed,  thymol  was  ad- 
miiiiBtered  in  1-grain  doses  every  four 
hours,  this  dose  afterward  being  doubled. 


CHYLURIA. 


CIAIICirUGA. 


lyi 


Under  this  medication  the  ILlarise  disap- 
peared after  a  few  weeks  from  the  blood, 
and  the  urine  gradually  improved  until 
in  about  two  months  it  had  resumed  its 
normal  character.  Two  months  later  no 
recurrence  of  the  pathological  condition 
had  taken  place.  Lawrie  (Indian  Med. 
Rec,  Mar.,  '90). 

Methylene-blue  tried  in  a  case  of  chy- 
luria  due  to  the  filaria  sanguinis  horn- 
inis.  The  effects  of  the  drug  were  de- 
cided and  prompt.  After  the  administra- 
tion of  2  grains  every  four  hours  dur- 
ing the  day,  on  March  5th,  the  parasites 
were  very  few  at  11  P.M.;  the  only  two 
found  were  deeply  stained  with  blue  and 
their  movements  were  extremely  slug- 
gish, the  urine  being  clear,  but  intensely 
blue.  On  the  fourth  and  the  seventh 
days  no  parasites  were  found,  although 
the  treatment  had  been  discontinued 
after  the  first  day.  On  the  eighth  day  the 
urine  became  milky,  and  on  the  night  of 
the  ninth  day  the  parasites  were  found 
in  great  number,  but  their  movements 
were  not  very  active.  On  the  tenth  day 
the  treatment  was  resumed  and  contin- 
ued for  five  days.  Three  days  after,  the 
blood  being  examined  at  night,  a  very 
few  motionless  filarite  were  observed. 
Since  that  time,  and  up  to  the  present 
writing  (more  than  a  year),  the  urine 
has  been  normal  and  the  patient  has 
been  restored  to  perfect  health.  Austin 
Flint  (N.  Y.  Med.  Jour.,  June  1.5,  '95). 
Case  of  chyluria,  the  first  of  the  kind 
observed  in  Philadelphia.  Microscopical 
examinations  of  the  blood  drawn  from 
the  finger  showed  that  the  parasites  were 
very  few  in  number  or  absent  from  the 
blood  during  the  day ;  they  were,  there- 
fore, the  variety  known  as  the  Filaria 
noctiinia.  Methylene-blue  in  2-gra;n 
capsules  every  three  hours  was  ordered. 
After  being  taken  continuously  for  sev- 
enty-two hours  the  blood  was  found  to 
contain  actively-moving  unstained  fila- 
riic.  The  urine  and  freces  were  stained 
a  deep  blue;  the  milk  was  uncolored. 
After  being  taken  for  nine  days  the  drug 
proved  absolutely  inert  so  far  as  any  in- 
fluence on  the  vitality  of  the  embryos 
was  concerned,  and  it  did  not  stain  them 
until  they  were  dead.  F.  P.  Henry  (Med. 
News,  May  2,  '96). 


Two  cases  of  chyluria  in  which  re- 
covery took  place  rapidly  under  the  use 
of  ichthyol  in  daily  amounts  of  7  or  8 
grains,  in  the  form  of  pills.  Moncorvo 
(Nouveaux  Rem6des,  Dec.  8,  '97). 
F.  Levison, 

Copenhagen. 

CILIARY  BODY.  See  Iris,  Ciliary 
Body,  and  Choroid. 

CmiCIFTJGA.  —  Black  cohosh  or 
black  snake-root.  The  rhizome  and  root- 
lets of  the  Cimicifuga  racemosa,  a  per- 
ennial plant  found  in  the  United  States 
and  Canada,  contains  an  acrid,  neutral 
alkaloid,  soluble  in  water,  dilute  alcohol, 
chloroform,  and  ether,  and  two  resins, 
one  of  which,  cimicifugin,  is  precipi- 
tated from  the  tincture  of  cimicifuga 
when  water  is  added  to  the  latter. 

Preparations  and  Dose. — It  is  impor- 
tant that  all  preparations  of  this  drug  he 
made  fresh,  since  they  deteriorate  upon 
keeping. 

Fluid  extract,  V2  drachm. 

Extract,  1  to  5  grains. 

Tincture  (20  per  cent.),l  to  2  drachms. 

Cimicifugin  or  macrotin  (resin),  V2  to 
2  grains. 

Physiological  Action.  —  Cimicifuga 
was  extensively  employed  by  the  abo- 
rigines of  North  America  as  an  aborti- 
facient,  its  action  in  this  particular 
greatly  resembling  that  of  ergot.  It  may 
be  used  when  the  latter  drug  cannot  be 
obtained  as  an  ecbolic,  not  only  during 
parturition,  but  in  post-parturition  haem- 
orrhage. In  moderate  doses  cimicifuga 
acts  as  a  diuretic  and  tends  to  increase 
the  bronchial  and  cutaneous  secretions, 
while  in  small  doses  it  stimulates  digest- 
ive functions,  acting  as  a  bitter  tonic. 
Its  influence  upon  the  heart  resembles 
that  of  digitalis;    large  doses  increase 


192 


CIMICIFUGA.    POISONING.    THERAPEUTICS. 


arterial  tension  and  cardiac  action,  while 
the  pulse  is  slowed.  The  latter  resixlt 
being  secondary,  the  use  of  the  drug, 
when  the  walls  of  the  organ  are  diseased, 
becomes  dangerous  in  large  doses. 

Poisoning  by  Cimicifuga. — A  typical 
case  of  poisoning  which  occurred  in  the 
person  of  a  physician  will  best  illustrate 
the  effects  of  an  excessive  dose. 

Dr.  I.  N.  Brainard  took  3  drachms  of 
the  fluid  extract  of  cimicifuga,  and  the 
effects  produced  by  the  drug  are  by  him 
described  as  follows:  In  about  half  an 
hour  had  a  feeling  of  fullness  in  the 
head;  the  face  was  flushed;  there  was  a 
sensation  of  warmth  all  over  the  body, 
with  vertigo,  which  was  increased  when 
in  the  erect  posture.  There  was  con- 
siderable pain  at  the  end  of  the  spine. 
After  an  hour  had  elapsed  all  these  symp- 
toms were  accentuated.  There  was  red- 
ness of  the  eyes,  but  the  pupils  were 
normal,  as  was  also  the  bodily  tempera- 
ture. The  pulse  was  100  and  full,  and 
there  was  marked  increase  in  the  arterial 
tension.  At  no  time  was  there  any  slow- 
ing of  the  pulse  or  any  signs  of  cardiac 
depression.  The  headache  now  became 
excessively  severe,  and  the  spinal  cord 
was  apparently  much  stimulated.  The 
muscles  in  the  back,  arms,  and  legs  were 
hard  and  trembling.  Two  hours  later 
these  symptoms  continued  with  increased 
severity,  and  nausea  then  appeared. 
There  was  increased  peristalsis,  but  no 
purging.  Four  hours  after  taking  the 
poison  he  drank  some  warm  water,  and 
vomited  three  times  during  the  next  five 
hours.  The  symptoms  continued,  never- 
theless, until  the  eighth  hour.  The  head- 
ache was  so  exceedingly  severe  that  it  was 
necessary  for  his  wife  to  anaesthetize  him 
with  chloroform.  There  was  a  great  deal 
of  backache  and  restlessness.  Eight 
hours  after  the  drug  was  taken  sleep 
came  on,  from  which  ho  awoke  several 


times  with  marked  priapism.  The  ef- 
fects upon  the  spinal  cord  and  nerves 
were  felt  for  a  little  over  two  days.  There 
was  considerable  increase  of  bronchial  se- 
cretion, but  no  increase  in  the  urinary 
flow  or  in  the  secretion  of  the  skin  was 
noticed  during  the  entire  period  of  the 
paroxysm. 

Therapeutics. — As  may  be  surmised 
from  its  physiological  properties,  cimici- 
fuga has  been  recommended  in  almost 
every  disease,  but,  being  superior  to  very 
few  drugs  which  possess  special  proper- 
ties of  a  more  restricted  kind,  it  has 
gradually  been  replaced  by  these.  Its 
most  marked  effects  are  probably  wit- 
nessed in  the  treatment  of  acute  rheu- 
matism, and,  according  to  Einger,  in 
rheumatoid  arthritis.  N.  H.  Bentley 
found  the  fluid  extract  valuable  in  rheu- 
matic myalgia,  while  Balfour  obtained 
considerable  assistance  for  the  relief  of 
pain  in  disorders  of  neuralgic  origin. 
Grouping  the  various  results  reported,  it 
would  seem  to  possess  analgesic  action, 
its  diuretic  properties  tending,  at  the 
same  time,  to  rid  the  economy  of  prod- 
ucts of  metabolism:  the  keynote  of  re- 
lief in  rheumatic  disorders. 

Another  disorder  in  which  cimicifuga 
sometimes  proves  superior  even  to  ar- 
senic is  chorea,  when  administered  in  full 
doses.  Its  action  in  this  disease  is  due 
to  its  influence  upon  the  reflex  centres  of 
tlic  spinal  cord. 

Cimicifuga  valuable  in  tinnitus  aurium. 
Conclusions: — 

1.  Buzzing  of  the  ear  may  bo  considered 
as  the  reaction  of  the  auditory  nerve  to 
direct  or  reflex  irritation.  2.  Gmlclfuga 
ruccmoHa  possesses  an  action  upon  the 
auricular  circulation  and  upon  the  reflex 
irritability  of  tlie  auditory  nerve;  the 
average  active  dose  is  30  drops  of  the 
extract  a  day.  3.  Huzzing  which  has  ex- 
isted more  than  two  years  appears  diffi- 
cult to  influence  by  cimicifuga.  Albert 
Robin  and  Mendel  (N.  Y.  Med.  Jour., 
July  23,  '98). 


CINCHONA.    SPECIES. 


193 


As  already  stated,  it  may  be  substi- 
tuted for  ergot  in  obstetrical  practice 
when  the  latter  drug  cannot  be  obtained, 
but  it  is  not  as  reliable.  Its  influence 
upon  the  uterine  circulation  and  the  in- 
voluntary muscular  fibre  causes  it  to  be 
very  effective  in  cases  of  uterine  con- 
gestion whatever  be  the  cause.  It  is, 
therefore,  frequently  employed  in  amen- 
orrhcEa,  dysmenorrhcea,  delayed  men- 
struation, the  menopause,  etc.,  when  con- 
gestion of  the  uterus  and  adnesa  plays 
an  active  part  in  the  morbid  process. 

CINCHONA. — Cinchona,  cr  cinchona- 
bark,  was  first  brought  to  Europe  some 
time  in  the  seventeenth  century,  but  just 
exactly  when  or  how  is  not  really  known, 
though  a  great  number  of  idle  and  fanci- 
ful tales  are  extant  that  purport  to  ac- 
count for  its  introduction.  It  was  cer- 
tainly employed  medicinally  as  early  as 
1640,  though  its  most  prominent  alka- 
loid, quinine,  was  not  discovered  until 
1820  (see  Quinine). 

Some  thirtj'-six  species  of  cinchona  are 
recognized,  and,  when  the  number  of 
hybrids  is  considered,  the  total  is  consid- 
erably augmented;  but  at  the  same  time 
only  seven  constitute  the  source  of  the 
principle  'Tjarks"  and  alkaloids  of  com- 
merce, as  follows: — 

Brown,  pale,  Loxa  (or  Loja)  bark,  ob- 
tained from  Cinchona  officinalis  and  the 
varieties  condaminea,  honplandiana,  and 
crispa;  red  bark,  from  C.  succirubra; 
gray,  or  silver,  bark,  from  C.  nitida,  C. 
micrantha,  and  C.  Peruviana;  yellow 
bark,  from  C.  calisaija  and  its  variety 
Lcdgeriana;  Columbian  or  Cartagenia 
bark,  from  C.  lancifolia  and  C.  cordi- 
folia ;  Pitaj'o  bark,  from  (7.  pitai/ensis ; 
and  Cuprea  bark  from  Ecmijia  Purdi- 
eana  and  7?.  pcduncuUta,  the  last  two  be- 
ing forms  seemingly  intermediate  as  to 
the  true  and  false  cinchonas.     All  are 


evergreen  trees  or  shrubs  that  favor 
mountain-ranges  and  slopes  at  elevations 
varying  from  400  to  11,500  feet  above 
sea-level;  they  average  from  30  to  SO 
feet  in  height,  and  measure  from  1  to  2 
feet  in  diameter  at  the  base.  The  leaves 
resemble  those  of  the  laurel,  are  entire, 
of  varying  shape,  the  best  pitted — or  with 
numerous  small  shallow  depressions — on 
the  under-side  (except  C.  succirubra)  and 
a  prominent  mid-rib;  flowers  tubular, 
fragrant,  rosy- white,  or  purplish;  fruit- 
capsule  two-celled,  splitting  from  the 
base  upward,  and  containing  many 
winged  seeds.  All  are  indigenous  to  the 
Andean  region  of  South  America,  and 
the  pale,  red,  and  yellow  barks  constitute 
the  chief  imports;  the  euprea-barks  are 
little  used.  Pale  and  red  barks,  the  prod- 
uct of  cinchona  plantations  in  India, 
instituted  and  fostered  by  the  govern- 
ment, are  also  obtained,  arriving  from 
Madras  and  other  seaports  on  the  Bay  of 
Bengal.  There  are  likewise  plantations 
in  Ceylon,  the  Malay  Peninsula,  in  South 
Africa,  Jamaica  in  the  West  Indies,  and 
a  very  rich  form  of  Ledgeriana  and  cali- 
saya  is  obtained  by  way  of  Amsterdam 
or  Hamburg  from  the  plantations  of  the 
Dutch  Government  in  Java.  Formerly 
the  trees  were  felled  close  to  the  ground 
and  stripped  of  bark,  not  even  the 
branches  escaping,  but  of  recent  years 
the  discovery  was  made  that  a  more 
profitable  jizld.  could  be  obtained  by 
merely  removing  the  bark  in  strips  or 
sections  from  the  standing  tree,  the  de- 
corticated portion  being  renewed  if  pro- 
tected, and  as  rich  in  alkaloids  as  before; 
also  that  the  yield  of  alkaloids  could  be 
materially  increased  by  covering  the  bark 
with  moss  or  matting,  thereby  prevent- 
ing the  rays  of  the  sun  from  converting 
the  alkaloids  into  coloring  matter. 
Again,  it  has  been  found  that  by  careful 
selection    of   favorable   species,    and    by 


194 


CINCHONA.    SPECIES. 


crossing  and  again  selecting,  barks  may 
be  produced  that  will  yield  double  or 
even  treble  the  quantity  produced  by  the 
best  non-hybrid  varieties. 

The  calisaya  is  one  of  the  most  im- 
portant of  the  "barks,"  inasmuch  as  qui- 
nine constitutes  from  one-fourth  to 
three-fourths  of  the  total  alkaloidal  yield. 
The  old  •'•'natural  flat  bark,"  the  product 
of  felling  and  stripping,  is  no  longer  met 
with,  but,  instead,  so  far  as  the  United 
States  is  concerned,  the  major  portion  is 
a  yellow  bark  rolled  from  flat  pieces, 
coming  from  Bolivia;  there  are  also 
"quilled"  and  doubly-quilled  varieties,  of 
variable  thicknesses,  from  3  inches  to  2 
feet  long,  ^/<  to  2  ^/^  inches  in  diameter 
and  Vi2  to  Ve  inch  thick,  with  a  longi- 
tudinally-wrinkled and  transversely-fis- 
sured, brown  epidermis,  the  latter  prac- 
tically tasteless  and  inert,  and  easily  sep- 
arated from  the  inner  or  medicinal  por- 
tion. This  bark  is  of  short,  fibrous  text- 
ure, compact,  presenting  shining  points 
wherever  broken,  of  brownish-yellow 
hue,  faint  odor,  and  bitter,  slightly-as- 
tringent taste. 

The  red  hark  has  many  alkaloids,  but 
does  not  yield  as  much  quinine  as  the 
calisaya.  It  comes  in  quills  and  flat 
pieces,  varying  in  thickness  from  Vs  to 
V<  inch,  is  of  deep-brown  or  brown-red 
color,  and  gives  a  short,  fibrous  fracture. 
The  epidermis  is  covered  with  warts  and 
ridges;  the  inner  surface  rather  coarsely 
striated.  It  gives  a  powder  of  a  deep 
brown-red  hue  that  is  slightly  odorous, 
but  astringent  and  bitter. 

Pale  harks  also  come  in  cylindrical 
pieces  of  variable  length,  sometimes 
singly,  sometimes  doubly  "quilled,"  are 
from  Vo  to  1  inch  in  diameter  and  from 
Vsi  to  Vo  (more  rarely  V*)  ^^  thickness. 
The  exterior  surface  is  rough,  of  a  gray- 
ish color,  with  transverse,  and  sometimes 
longitudinal,    fissures;    interior   surface 


either  rough  or  smooth,  according  to  the 
period  of  gathering;  fracture  smooth, 
with  some  short  filaments  on  the  inner 
surface;  faintly-aromatic  odor,  and  mod- 
erately bitter  and  astringent  taste.  Of 
the  total  alkaloids,  from  50  to  65  per 
cent,  is  quinine. 

Thianuco,  or  g7-ay  bark,  of  a  cultivated 
variety  and  much  richer  than  the  pale 
forms  in  quinine,  is  now  obtained  from 
Jamaica.  The  quills  are  frequently 
somewhat  spirally  rolled,  and  on  the  epi- 
dermis are  numerous  short,  irregular, 
transverse  cracks;  the  edges  are  flat, 
scarcely  separated  or  everted;  the  outer 
surface  is  whitish  or  of  a  clear  silvery 
gray,  or  in  the  smaller  quills  of  a  uniform 
whitish-gray;  inner  surface  yellow,  yel- 
lowish-red, sometimes  cinnamon-brown; 
smooth  in  small  quills  and  fibrous  in 
large;  fracture  smooth  and  resinous,  odor 
claj'ish  and  pleasant;  taste  astringent, 
aromatic  and  bitter.  The  bark  from  C. 
nitida  is  not  wrinkled  longitudinally  on 
the  derm,  and  the  inner  portion  is  of  a 
more  or  less  brown  hue;  but  the  product 
of  C.  micranlha  is  often  wrinkled  longi- 
tudinally, though  almost  devoid  of  trans- 
verse fissures;  it  has  a  rusty-yellow  in- 
terior. As  obtained  uncultivated  from 
South  America,  these  gray  barks  yield 
less  than  3  per  cent,  of  alkaloids,  often 
but  1.5  per  cent.,  of  which  but  from  "/,(, 
to  °/i5  per  cent,  is  quinine. 

Columbian,  or  Cartagean,  barks  are  of 
two  forms.  That  from  C.  lancifolia  is 
chiefly  from  young  stems  and  branches, 
are  usually  "quilled"  and  coated  with  a 
brownish-yellow  epidermis,  in  turn 
perhaps  coated  with  white  crustaccous 
lichens,  causing  it  to  assume  a  grayish 
or  silvery  appearance.  The  quills  vary  in 
size  from  "/„  to  1  V2  inches  in  diameter, 
some  being  rather  smooth,  others  rough, 
owing  to  numerous  short,  slight,  longi- 
tudinal   and    transverse    cracks;     edges 


CINCHONA.    PREPARATIONS  AND  DOSES. 


195 


slightly  everted;  extremely  fibrous  and 
moderately  bitter.  It  is  not  uncommon 
to  find  the  "quills"  trimmed:  i.e.,  with 
the  epidermis  removed.  The  interior 
may  be  reddish,  orange-yellow,  or  yellow; 
hence  it  is  not  always  easily  distinguished 
from  the  gray  barks.  The  cordifolia 
form  occurs  both  as  flat  pieces  and  as 
fine,  middling,  and  thick  quills;  the  flat 
pieces  more  or  less  twisted,  arched,  and 
warped;  from  V2  ^o  ^  inches  broad,  4  to 
8  or  12  inches  long,  and  V„  to  %  inch 
thick.  The  quills  vary  from  5  to  12 
inches  in  length,  are  from  V4  to  'A  inch 
in  diameter,  and  V,.,  to  V4  inch  thick, 
and  also  are  frequently  deprived  of  epi- 
dermis. The  interior  surface  of  both 
forms  varies  from  smooth  to  flbrous,  the 
prevailing  hue  being  of  a  pale-ochre  yel- 
low, in  old  species  brownish.  The  fibres 
often  project  obliquely,  giving  a  scaly, 
fibrous  appearance.  The  epidermis,  when 
present,  is  observed  of  a  whitish,  yellow- 
ish-white or  ash-gray  hue,  with  irregular, 
flexuous,  longitudinal,  but  not  very  deep 
furrows.  The  fracture,  if  transverse,  is 
short,  internally  more  or  less  fibrous,  ex- 
ternally corky;  longitudinally  it  is  un- 
even, short,  coarse,  and  splintery,  and 
often  eilected  only  with  difficulty.  The 
powder  is  of  cinnamon-hue,  moderately 
bitter  and  astringent.  Both  the  fore- 
going barks  vary  materially  in  their  yield 
of  alkaloids. 

Pelaya  harh  is  of  little  interest  save 
to  manufacturers  of  alkaloids,  and  con- 
tains from  1.5  to  1.8  per  cent,  of  quinine. 
It  comes  in  short  quills  or  curly  pieces 
of  a  brownish  color,  and  is  especially  rich 
in  quinidine. 

The  cuprea  barks  come  in  short  red 
quills  and  broken  pieces,  and  are  not 
true  cinchona-barks,  but  are  here  men- 
tioned because  they  are  a  source  of  cin- 
chona alkaloids;  they  contain  quinine, 
quinidine,  cinchonine,  but  no  cinchono- 


dine,  and  also  cupreine:  an  alkaloid  that 
exists  in  connection  with  the  first  named, 
and  was  formerly  held  to  be  a  distinct 
entity  to  which  the  titles  of  "homo- 
quinine"  and  "ultraquinine"  were  given. 

The  cinchonas  are  incompatible  with 
tinctures  of  iodine,  tannin,  alkalies  and 
alkaline  carbonates;  are  antagonized  by 
mercury,  iodides,  and  the  salts  of  lead, 
zinc,  and  copper. 

Preparations  and  Doses. — Cinchona- 
bark,  powdered, — all  forms, — 10  to  60 
grains  and  upward. 

Cinchona  decoction  (cinchona,  10 
drachms;  distilled  water,  16  ounces),  1 
to  2  ounces. 

Cinchona  infusion  (cinchona,  1  ounce; 
water,  16  ounces),  1  to  2  ounces. 

Cinchona  infusion,  acid  (red  bark,  4 
drachms;  boiling  distilled  water,  10 
ounces;  aromatic  sulphuric  acid,  1 
drachm),  1  to  2  ounces. 

Cinchona  infusion,  compound  (red 
cinchona,  1  ounce;  Virginia  snake-root, 
2  drachms;  boiling  water,  24  ounces;  in- 
fuse and  evaporate  to  1  pint,  and  add  4 
ounces  of  spirit  of  Mindererus),  1  to  2 
ounces. 

Cinchona  infusion,  inspissated,  30  to 
60  minims  (obsolete). 

Cinchona  extract,  solid  (pale  and  yel- 
low forms),  5  to  30  grains. 

Cinchona  extract,  solid  (calasaya),  hy- 
dro-alcoholic, 2  to  15  grains. 

Cinchona  extract,  solid  (red),  2  to  30 
grains. 

Cinchona  extract,  solid  (red),  alco- 
holic, 2  to  30  grains. 

Cinchona  extract,  fluid  (pale  and  yel- 
low— 5  per  cent,  total  alkaloids),  5  to  30 
minims. 

Cinchona  extract,  fluid,  aromatic,  20 
to  120  minims. 

Cinchona  extract,  fluid  (red),  5  to  30 
minims. 


196 


CINCHONA.    PREPARATIONS  AND  DOSES. 


Cinchona  extract,  fluid  (red),  com- 
pound, 20  to  90  minims. 

Cinchona  extract,  fluid  (red),  detan- 
nated,  20  to  90  minims. 

Cinchona  tincture  (pale  and  yellow 
forms),  1  to  4  drachms. 

Cinchona  tincture  (red),  30  to  130 
minims. 

Cinchona  tincture  (red),  compound 
(Huxam's),  30  to  120  minims. 

Cinchona  tincture  (red),  compound 
("\\Tiytt's),  30  to  120  minims. 

Cinchona  tincture,  ammoniated,  30  to 
120  minims. 

Cinchona  tincture,  ferrated,  20  to  60 
minims. 

Cinchona-wine  (cinchona  tincture,  10 
parts;  sherry-wine  and  .glycerin,  of  each, 
30  parts),  1  to  4  drachms. 

Cinchona-wine,  aromatic,  1  to  4 
drachms. 

Cinchona  elixir,  B.  P.,  30  to  60  min- 
ims; TJ.  S.  P.,  1  to  2  drachms. 

Cinchonine  crystals,  1  to  40  grains. 

Cinchonine  benzoate,  1  to  5  grains. 

Cinchonine  bisulphate,  1  to  30  grains. 

Cinchonine  iodosulphate,  1  to  3  grains. 

Cinchonine  and  iron  tartrate,  3  to  8 
grains. 

Cinchonine  salicylate,  3  to  15  grains. 

Cinchonine  picrate,  1  to  3  grains. 

Cinchonine  sulphate,  2  to  30  grains. 

Cinchonine  tannate,  2  to  30  grains. 

Cinchonidine  crystals,  1  to  20  grains. 

Cinchonidine  bisulphate,  1  to  20 
grains. 

Cinchonidine  borate,  1  to  10  grains. 

Cinchonidine  dihydrobromate,  1  to  10 
grains. 

Cinchoni'lino  bydrochlorate,  2  to  20 
grains. 

Cinchonidine  salicylate,  1  to  10  grains. 

Cinchonidine  sulphate,  1  to  30  grains. 

Cinchonidine  tannate,  5  to  15  grains. 

Cinchonidine  tartrate,  2  to  15  grains. 

Quinetum  (chinetum),  1  to  8  grains. 


Quinetum  sulphate,  1  to  8  grains. 

Quinidine  (chinidine,  conchinine),  3 
to  30  grains. 

Quinidine  bisulphate,  5  to  60  grains. 

Quinidine  citrate,  1  to  12  grains. 

Quinidine  dihydrobromate,  5  to  50 
grains. 

Quinidine  hydrobromate,  5  to  50 
grains. 

Quinidine  sulphate,  5  to  60  grains. 

Quinidine  tannate,  5  to  15  grains. 

Quinoidine  (chinoidine),  2  to  15 
grains. 

Quinoidine  borate,  8  to  15  grains. 

Quinoidine  citrate,  5  to  25  grains. 

Quinoidine  hydrochl orate,  5  to  25 
grains. 

Quinoidine  sulphate,  5  to  25  grains. 

Quinoidine  tannate,  5  to  15  grains. 

Quinoline  (true,  from  cinchonine),  15 
to  30  minims. 

Quinine,  alkaloid,  2  to  15  grains  (see 
Quinine). 

Cinchona  febrifuge  (see  Quinetum, 
on  pages  197  and  200). 

Cupreine,  1  to  15  grains. 

Cupreine  sulphate,  1  to  15  grains. 

Esencia  de  calasaya,  4  to  12  drachms. 

Compound  elixirs  of  cinchona  (all 
kinds),  1  to  2  drachms. 

ITeberden's  ink  (aromatic  iron  and  cin- 
chona mixture),  1  to  2  ounces. 

Homoquinine  (mixture  of  quinine  and 
cupreine),  1  to  15  grains. 

Cinchonine  and  Salts. — The  alkaloid 
appears  as  white  shining  prisms  or  nee- 
dles, at  first  without  much  taste,  but 
after  being  swallowed  developing  a  dis- 
tinct bitterness  on  tongue  and  palate; 
it  is  soluble  in  dilute  acid,  in  alcohol  1 
to  116,  chloroform  1  to  163,  and  very 
slowly  so  in  ether  and  water. 

The  bemoaie  is  soluble  in  alcohol, 
slowly  so  in  water,  and  comes  in  the 
form  of  small  white  crystals. 

The    hisulphide    appears    in    rainutc' 


CIAX'HONA.    PKEPAKATIONS-AND  DOSES. 


197 


trisnetric  prisms,  soluble  in  water  and  in 
alcohol. 

lodosulphaie  of  cinchonine  is  a  dark- 
brown,  odorless  powder  containing  50 
per  cent,  of  iodine,  and,  though  some- 
times administered  internally,  it  finds  its 
principal  use  as  an  external  application 
and  substitute  for  iodoform;  it  is  freely 
soluble  in  alcohol  and  chloroform; 
slowly  soluble  in  water. 

Nitrate  of  cinchonine  appears  as  color- 
less prisms,  soluble  in  water;  its  value  is 
about  the  same  as  any  other  ordinary  salt 
of  the  alkaloid. 

Salicylate  of  cinchonine,  introduced  as 
a  remedy  for  rheumatism,  has  never 
equaled  the  expectations;  it  comes  in 
white  crystals,  soluble  in  alcohol. 

Cinchonine  sulphate  is  a  fair  substi- 
tute at  times  for  other  cinchona  alka- 
loids; is  obtained  in  hard,  white,  lus- 
trous crystals  of  very  bitter  taste.  It  is 
soluble  in  10  parts  of  alcohol,  about  65 
parts  of  water,  and  75  to  80  of  chloro- 
form. 

The  tannate  salt  is  of  variable  com- 
position, like  most  tannates;  it  is  an 
amorphous,  yellow  powder,  by  no  means 
constant  as  to  color,  slowly  soluble  in 
water,  and  readily  so  in  alcohol. 

Cinchonidine  is  usually  obtained  from 
the  red  cinchona,  and  may  appear  either 
as  white  prisms,  or  a  white  powder,  or 
in  light,  white  masses,  and  has  an  intense 
bitter  taste;  is  soluble  in  alcohol,  ether, 
and  chloroform,  in  dilute  acids,  and  in 
water  slowly. 

Cinchonidine  bisulphate  is  soluble  in 
water  and  alcohol,  and  comes  in  striated 
prisms.  Another  salt  of  no  material 
value  is  the  borate :  a  white  powder  that 
is  soluble  only  in  alcohol. 

The  dihydrohrornate,  h/drochloraic,  and 
hydroiodatc  salts  appear,  respectively,  as 
slightly  yellowish  prisms,  white  prisms, 
and    yellowish-white    crystals;     all    are 


soluble  in  water,  and  the  hydrochlorate 
in  alcohol  and  chloroform  as  well. 

The  salicylate  of  cinchonidine  appears 
as  white  colorless  microscopical  crystals, 
soluble  in  alcohol,  very  slowly  so  in 
water. 

Cincho7iidine  sulphate  presents  white, 
silky,  acicular  crystals  that  effloresce  on 
exposure;  is  soluble  in  alcohol  and  hot 
water;  slowly  so  in  cold  water. 

The  tannate  is  a  yellow,  amorphous 
powder,  practically  tasteless,  of  uncertain 
and  variable  composition. 

Cinchonine  tartrate,  very  slowly  sol- 
uble in  water,  rapidly  so  in  alcohol,  is  a 
white  crystal  powder. 

Quinetum,  known  also  as  chinetum, 
kinetum,  and  cinchona  febrifuge,  is  a 
mixture  of  the  alkaloids  of  red  cinchona- 
bark,  devised  by  East  Indian  authorities 
as  a  better,  cheaper,  and  safer  remedy 
than  quinine,  and  it  seems  to  have  met 
with  general  favor.  In  the  United  States 
is  prepared  an  elixir  of  all  the  cinchona 
alkaloids  that  is  most  palatable,  known 
as  "esencia  de  calasaya,"  which  is  in- 
tended for  the  same  precise  purpose. 
Quinetum  is  an  amorphous,  grayish- 
white  powder,  containing  from  50  to  70 
per  cent,  of  cinchonidine;  is  soluble  in 
dilute  acids  and  slowly  so  in  water. 
Quionin  purports  to  be  much  the  same 
thing,  but  is  more  uncertain  as  to  com- 
position. There  is  also  a  neutral  sul- 
phate of  quinetum  prepared. 

Quinidine,  chinidine.  or  conchinine, 
has  the  form  of  colorless,  lustreless 
prisms,  and  effloresces  on  exposure;  is 
soluble,  1  to  20,  in  alcohol,  1  to  30  in 
ether,  and  1  to  2000  in  water.  Both  a 
sulphate  and  hisulphatc  are  had,  the 
former  as  white  needles,  the  latter  as 
long,  colorless  crj'stals.  both  being  ex- 
tremely bitter;  the  sulphate  is  soluble, 
1  to  8,  in  alcohol,  1  to  14  in  chloroform, 
1  to  100  in  water,  while  the  bisulphate 


198 


CINCHONA.    PHYSIOLOGICAL  ACTION. 


is  soluble  (with  fluorescence)  in  water 
only. 

The  dihydrolromate,  hydrdbromate,  and 
hydrochlorate  are  all  white  cr}'stal  salts, 
all  soluble  in  water,  and  the  last  two 
also  in  alcohol. 

The  tannate  is  an  amorphous,  taste- 
less, white  powder  only  partly  soluble  in 
alcohol. 

Quinoidine,  or  chinoidine,  is  a  mixt- 
ure of  amorphous  alkaloids  that  remain 
in  solution  after  the  crystalline  alkaloids 
have  been  separated.  It  is  a  very  bitter, 
brownish-black  mass,  lustrous  and  resin- 
ous in  appearance,  soluble  in  dilute  acids, 
alcohol,  and  chloroform,  and  softens  at 
a  temperature  of  212°  or  less.  The 
borate  and  citrate  appear  as  yellowish- 
brown  and  reddish-brown  scales,  re- 
spectively, and  both  are  soluble  in  water 
and  alcohol.  The  hydrochlorate  and  sul- 
phate are  bitter  white  powders,  alike 
soluble  in  alcohol  and  water.  The 
tannate  is  a  yellow  or  brownish  amor- 
phous powder  partly  soluble  in  alcohol. 

Quinoline,  for  the  most  part,  is  a  ter- 
tiary amine  derived  synthetically  from 
aniline,  or  naturally  from  coal-tar, 
though  it  can  also  be  had  from  cincho- 
nine.  It  is  a  colorless  liquid  of  peculiar 
odor,  that  turns  yellow  with  age,  and  is 
lauded  as  an  antiseptic;  a  large  number 
of  salts  are  made,  but  these  are  not  de- 
rived from  the  cinchonine  product, 
which  is  five  times  as  expensive  as  the 
synthetic  or  that  had  from  coal-tar. 

For  description  of  the  quinine  alka- 
loids see  Quinine. 

Quinic,  or  Icinic,  acid  is  another  de- 
rivative of  the  cinchona-barks,  with  a 
decided  acid  taste,  soluble  in  water  and 
alcohol,  and  obtained  in  the  form  of 
hard,  white,  transparent,  monoclinic 
prisms. 

Qiiinolinic  acid  is  no  longer  had  from 
cinchonine,  but  from  the  artificial  prod- 


uct; and  the  same  is  true  of  the  quino- 
sulphuric  acids. 

Quinopicric  acid  is  a  yellowish-brown 
powder  made  by  mixing  quinine  and  cin- 
chonine picrates. 

Quinovic  acid  is  secured  from  quino- 
vin,  derived  from  certain  cinchonas. 
These  two,  quinidamine,  quinquinia, 
quinicine,  quinone,  and  quinotannic  acid 
are  obsolete,  reclassified,  and  rearranged, 
or  no  longer  obtained  from  cinchona- 
barks  or  alkaloids,  but  as  the  result  of 
chemical  enterprise  in  connection  with 
aniline  and  the  coal-tar  products. 

Physiological  Action.  —  The  physio- 
logical effects  of  the  cinchona-barks  and 
their  alkaloids  are  so  inextricably  bound 
up  with  the  action  of  quinine  that  they 
cannot  well  be  separated;  therefore  only 
a  brief  resume  can  be  here  given;  for 
more  elaborate  description,  the  reader  is 
referred  to  Quinine. 

Cinchona  is  about  fifty  times  more 
bulky  than  its  alkaloids,  is  more  astrin- 
gent, more  apt  to  irritate  the  stomach, 
and  much  more  difficult  of  absorption. 
Given  in  sufficient  doses,  cinchona  and 
its  alkaloids  are  antiperiodic,  tonic, 
febrifuge,  and  to  some  degTce  antiseptic. 
In  small  doses  no  sensible  effect  is  pro- 
duced, except,  perhaps,  with  the  excep- 
tion of  slight  arterial  excitement,  though 
some,  who  may  be  particularly  sensi- 
tive to  the  drug,  may  exhibit  an  in- 
creased flow  of  animal  spirits.  Taken 
in  medium  doses,  just  before  retiring  at 
night,  they  sometimes  induce  sleepless- 
ness. In  large  or  long-continued  doses 
headache  may  be  induced,  along  with 
deafness,  noises  or  ringing  in  the  ears, 
flashings  of  light  across  the  eyes,  vertigo, 
nausea,  and  even  delirium  and  coma  if 
pushed  to  extremes.  The  supervention 
of  any  of  these  symptoms,  called  "cin- 
cbonism,"  indicates  that  the  full  physio- 
logical effects  have  been  produced,  and 


CINCHONA.     POISONING.    THERAPEUTICS. 


199 


that  no  further  benefit  can  be  obtained 
by  persevering  in  administration.  The 
action  is  much  more  rapid  and  energetic 
when  given  on  an  empty  stomach,  espe- 
cially after  considerable  abstinence  from 
food,  or  when  combined  with  an  acid, 
than  when  given  after  meals  or  in  merely 
a  semisoluble  state.  The  drugs,  more- 
over, appear  to  be — at  least  in  consid- 
erable proportion — taken  up  by  the  cir- 
culation with  the  result  of  depriving  the 
blood  to  greater  or  less  extent  of  its  co- 
agulability; in  fact,  when  the  dose  is 
sulKciently  large  the  action  is  like  that 
of  any  other  poisonous  agent.  No  doubt, 
the  reflex  excitability  of  the  cord  is 
diminished  on  occasions,  though  this 
has,  in  many  instances,  been  denied. 
Small  doses  tend  to  increase  the  secre- 
tion, while  large  produce  a  diametric- 
ally-opposite effect.  Respiration  appears 
not  to  be  influenced.  Large  doses  ex- 
hibited during  a  febrile  paroxysm  ma- 
terially depress  temperature.  The  alka- 
loidal  salts  may  be  detected  in  consider- 
able quantities  in  the  urine  in  from  30 
to  GO  minutes  after  ingestion,  but  where 
the  bark  is  exhibited  transformation  and 
elimination  may  be  materially  delayed. 
Elimination  is  usually  at  its  height,  in 
any  event,  during  the  third  hour;  di- 
minishes in  twenty-four  hours;  and 
ceases  about  the  third  day.  Although 
traces  of  salts  may  be  foimd  in  the  saliva, 
perspiration,  and  the  secretions  and  ex- 
cretions of  the  intestines,  the  bulk  of 
elimination  is  by  the  kidneys,  and  the 
amount  of  uric  acid  in  the  urine,  particu- 
larly in  malarial  poisoning,  is  apt  to  be 
decreased.  Most  of  the  salts  have  an  oxy- 
toxic  action. 

Poisoning  by  Cinchona.— The  fatal 
dose  of  any  cinchona  alkaloid  is  un- 
known, and,  as  regards  the  bark,  it  would 
be  difficult  to  ingest  enough  to  cause  fa- 
tality, because  of  the  facility  with  which 


the  stomach  rejects  enormous  doses.  Cin- 
chonism,  already  mentioned  (see  Physio- 
logical Action),  moreover,  affords  am- 
ple warning  of  untoward  effects.  A  full 
ounce  of  quinine  has  been  ingested  at  a 
single  dose  without  inducing  any  very 
alarming  effects,  but  foreign  literature 
records  a  case  whore  5  ounces  proved 
fatal. 

The  skin  of  many  persons  is  affected 
in  a  peculiar  way  by  the  internal  adminis- 
tration of  the  alkaloidal  salts;  these  erup- 
tions may  present  any  of  the  forms  of 
purpura,  roseola,  eczema,  pemphigus,  or 
even  the  exanthem  of  scarlatina. 

Case  in  which,  two  days  after  taking 
15-drop  doses  of  compound  tincture  of 
cinchona,   a   patient   complained   of   in- 
tolerable  itching,   which   was   soon   fol- 
lowed  by  vesiculation   on   the  genitals, 
face,  and  ears;  the  whole  general  surface 
of  the  body  rapidly  became  the  seat  of  a 
scarlatinoid  dermatitis.     As  this  began 
to  decline,  the  palms  and  soles  became 
affected   with   blebs,   as   much   as   eight 
ounces  of  serum  being  evacuated.     The 
blebs   recurred,   and   it  was   five   or  six 
weeks  before  recovery  was  complete,  the 
palms   being  the   last   to   recover.     The 
same    phenomena    had    before    occurred 
from  the  administration  of  quinine.    The 
chief  points  of  interest  are  the  variety  of 
the  bulbous  manifestations  and  the  great 
disproportion    between    the    violence    of 
the  cutaneous  outbreaks  and  the  small 
amount  of  the  drug  ingested.    Johnston 
(M.d.  Age.,  Aug.  25,  '97). 
Therapeutics.  —  Cinchona  -  bark      no 
longer    receives    general    employment, 
partly    owing   to    the   large    doses    de- 
manded, and  partly  because  of  the  su- 
periority of  the  alkaloids,  either  singly 
or  mixed.    Once  in  a  great  while  it  finds 
use  in  the  application  of  a  "cinchona 
jacket"  in  the  agues  of  children,  the 
powdered  red  bark  being  quilted  between 
two  folds  of  the  garment,  which  is  ap- 
plied next  to  the  skin.     Cinchona  (red) 
and  snake-root,  with  spirit  of  Mindererus 
is  also  often  employed  as  a  tonic  and 


200 


CINCHONA.    THEKAPEUTICS. 


stimulant  in  low  forms  of  fever,  typhoid 
more  particularly. 

Cinchonine  alkaloid  is  found  chiefly  in 
the  pale  varieties  of  bark.  Its  action 
(and  likewise  that  of  its  salts),  is  very 
similar  to  that  of  quinine,  but  less  ener- 
getic, and  requires  to  be  given  in  larger 
doses;  it  is  sometimes  substituted  for 
quinine,  being  cheaper,  and  when  the 
latter  commanded  a  high  price  cinchona 
was  often  employed  as  an  adulterant. 

In  intermittent  it  has  an  unquestion- 
able, but  variable,  action;  sometimes  its 
action  is  slow,  whatever  the  dose  exhib- 
ited, and  the  paroxysms  cease  gradually. 
It  is  only  about  two-thirds  as  active  as 
quinine:  a  fact  that  must  be  considered 
when  prescribing.  Again,  in  doses  of  10 
to  15  grains  it  sometimes  induces  cin- 
chonism,  and  which  it  is  not  usually 
prudent  to  exaggerate;  further,  its  thera- 
peutic action  is  not  always  proportion- 
ate to  the  physiological  effects;  for, 
while  it  sometimes  answers  the  purpose 
for  which  it  is  prescribed  without  the 
latter  being  manifested,  on  the  other 
hand,  the  physiological  effects  may  be 
most  energetic,  without  any  evidence  of 
therapeutic  activity.  It  certainly  can- 
not wholly  replace  quinine  or  its  salts  in 
severe  intermittents  or  remittents,  but 
may  prove  a  valuable  adjunct.  The  hy- 
drochlorate  salt  is  admittedly  the  best 
form  for  administration,  though  the  sul- 
phate is,  perhaps,  more  generally  em- 
ployed. 

Cinchonine  appears  to  act  very  much 
in  the  same  way  as  quinine,  but  less  pow- 
erfully; it  depresses  the  heart  more  than 
quinine  does.     (Whitla.) 

According  to  Wood,  it  is  about  one- 
third  weaker  than  quinine,  and  must  be 
lised  in  correspondingly  larger  doses. 

Cinchonine  is  recommended  as  a  feb- 
rifuge for  children  because  it  is  nearly 
tastelcBB. 


The  cinchona  alkaloids,  when  swal- 
lowed in  insoluble  form,  combine  with 
the  acids  of  the  gastric  juice  and  become 
soluble;  so  that,  as  a  mere  solvent,  it  is 
unnecessary  to  administer  cinchonine 
with  acids,  and  a  large  dose  merely  sus- 
pended in  fluid  is  quite  as  efficacious  as 
when  dissolved. 

Many  observers  consider  that  cincho- 
nine is  superior  to  quinine  as  a  prophy- 
lactic. This  alkaloid  passes  off  in  part  by 
the  urine,  but  a  portion  appears  to  be 
consumed  in  the  blood  or  to  be  elim- 
inated in  some  other  way. 

Cinchonidine  is  accepted  as  isomeric 
with  cinchonine,  and  its  alkaloids  are 
used  to  a  small  extent  as  a  substitute  for 
the  latter  and  its  derivatives,  or  for  qui- 
nine salts;  like  all  the  derivatives  of 
cinchona,  it  is  toxic  and  antiperiodic.  It 
is  distinguished  from  cinchonine  by  its 
solution  being  levogyrate,  and  from  qui- 
nine and  true  quinidine  by  its  acid  solu- 
tion not  being  fluorescent.  Cinchonine 
solutions  are  dextrogyrate,  and  its  acid 
solutions  are  not  fluorescent;  like  cin- 
chonidine, it  does  not  give  an  emerald- 
green  color  with  chlorine-water  and  am- 
monia like  quinine  and  quinidine. 

According  to  Whitla,  cinchonidine  re- 
sembles both  quinine  and  cinchonine  in 
action,  but  is  less  powerful  than  the  first, 
being  about  equal  to  the  latter.  Like 
cinchonine,  it  depresses  the  heart  more 
than  quinine. 

Clinical  experience  lias  proved  the 
cinchonidine  salts  to  be  reliable  tonics 
and  antiperiodics.  They  are  said  to  be 
eliminated  by  the  kidneys  unchanged; 
also  to  produce  less  disagreeable  symp- 
toms, both  gastric  and  cerebral,  than 
quinine;  but  Eafferty,  who  administered 
more  than  three  hundred  ounces,  affirms 
that  it  is  apt  to  cause  nausea  and  vomit- 
ing.    (Wood.) 

Quinetum. — This,     as     before     men- 


CINCHONA.    THERAPEUTICS. 


201 


tioned,  is  known  also  as  "cinchona  febri- 
fuge." It  is  an  amorphous,  dirty-white 
powder  consisting  of  mixed  alkaloids  ob- 
tained from  the  red-cinchona  grove  at 
the  government  plantations,  Darjeeling, 
India;  the  alkaloids  are  in  the  same  pro- 
portion as  found  in  the  bark.  The  sul- 
phate is  a  more  presentable  salt,  and  re- 
sembles quinine  sulphate.  As  the  sub- 
stance known  as  quinetum  consists 
chiefly  of  cinchonidine  salts  (from  50  to 
70  per  cent.),  these  latter  probably  will 
offer  an  efficient  substitute.  Neverthe- 
less, it  has  almost  replaced  quinine  in 
India,  and  is  said  to  be  more  readily 
absorbed  into  the  system  than  the  crys- 
talline alkaloids. 

It  is  a  well-known  fact  that  the  com- 
bined alkaloids  of  the  cinchona-bark  are 
much  more  effective  as  a  tonic  than  any 
one  of  them  taken  singly.  They  are  to 
be  preferred  in  combination  also,  in  many 
instances,  as  an  antiperiodic,  particularly 
when  the  periodicity  of  the  attack  has 
been  in  some  degree  mitigated.  It  is  for 
this  reason  that  the  East  Indian  Govern- 
ment now  provides  its  officials  with  "cin- 
chona febrifuge," — which  is  merely  a 
combination  of  cinchona  alkaloids — in 
preference  to  quinine.  While  cases  are 
encountered  where  quinine  is  practically 
indispensable  for  a  time,  there  are  few 
which  will  not  readily  yield,  and  more 
satisfactorily,  to  a  combination  of  cin- 
chona alkaloids.  Esencia  de  calasaya  and 
cinchona  febrifuge  are  practically  iden- 
tical, save  that  the  former  is  a  fluid 
medicament,  the  latter  a  powder.  The 
esencia,  moreover,  is  an  ideal  general 
tonic,  and  is  particularly  useful  in  atonic 
dyspepsia.  In  the  alcohol  habit  it  satis- 
factorily neutralizes  the  craving  for  spir- 
its, and  will  be  found  of  great  service  in 
treating  this  disease.  Wingrave,  Lond. 
(Jled.  Age,  Sept.  2.5,  '93). 

Quinidine  is  believed  to  have  the  same 
action  and  medical  properties  as  other 
cinchona  salts,  and  to  be  equally  as  effi- 
cacious as  quinine  without  giving  rise 
to  the  disagreeable  nervous  effects  occa- 


sionally observed  when  the  latter  is  given 
in  large  doses.  Hare  says  the  dose  should 
be  double  that  of  quinine,  but  it  would 
seem  preferable  not  to  greatly  surpass 
the  dose  of  quinine. 

Quinoidine,  or  Chinoidine. — There  is 
little  to  say  regarding  this  substance 
further  than  that  it  partakes  of  the  na- 
ture and  characteristics  of  other  cin- 
chona preparations.  As  before  remarked, 
it  is  a  bj'-product,  chiefly  a  mixture  of 
such  alkaloids  as  are  not  readily  ex- 
tracted, left  after  the  major  portion  of 
the  same  have  been  crystallized  out.  It 
may  be  resolved  into  ordinary  quinine, 
cinchonine,  and  quinidine  alkaloids,  but 
is  not  generally  held  a  profitable  measure. 
Solutions  in  either  boric  or  sulphuric 
acid  are  employed  as  cheap  febrifuges, 
but  their  taste  is  verj'  nauseous.  Quinoi- 
dine is  neither  as  certain  in  composition 
or  uniform  in  effects  as  quinetum. 

Quinovic,  kinovic,  or  chinovic  acid  is 
little  employed,  as  it  offers  no  advan- 
tages over  other  cinchona  derivatives:  it 
poses  rather  as  a  chemical  curiosity  than 
as  a  medicament. 

Cupreine  is  nearly  allied  to  quinine, 
and  generally  on  extraction  from  cuprea- 
bark  found  conjoined  with  the  latter:  a 
combination  that  for  a  time  obtained  the 
title  of  homoquinine,  it  being  supposed 
to  be  a  specific  alkaloidal  entity.  Both 
sulphate  and  muriate  salts  are  manufact- 
ured, but  neither  the  two  latter  nor  the 
alkaloid — though  purported  to  be  equally 
as  efficacious  therapeutically  as  the  qui- 
nine and  its  salts — have  as  yet  secured  a 
permanent  position  in  the  materia  med- 
ica. 

For  further  consideration  of  the  thera- 
peutics of  the  cinchonas  and  their  de- 
rivatives, the  reader  is  referred  to  Qui- 

NIXE. 

G.  Archie  Stockwell, 

New  York. 


202 


CIXXAilON.    PHYSIOLOGICAL  ACTION.    THERAPEUTICS. 


CINNAMON  AND  DERIVATIVES.— 

Cinnamon  is  the  inner  bark  of  the  shoots 
of  the  Cinnamomum  Zeylandicum  and 
C.  aromaticum :  beautiful  eyergreen 
trees  twenty  to  thirty  feet  high  and 
twelve  to  eighteen  inches  in  diameter, 
cultivated  in  many  portions  of  the  East 
Indies-.  The  bark  comes  in  long,  closely- 
rolled  quills,  composed  of  eight  or  more 
layers;  is  of  pale-yellowish-brown  hue, 
the  inner  surface  striated;  fracture 
splintery;  odor  fragrant  and  warmly  aro- 
matic, and  taste  sweet.  Some  forms  are 
more  coarse  in  taste  and  odor.  Cassia- 
buds  are  the  calyces  surrounding  the 
young  germ.  The  term  "cassia"  is  fre- 
quently applied  to  Chinese  and  Saigon 
cinnamon,  which  is  less  expensive  and 
more  generally  marketed  in  the  United 
States  than  Ceylon  cinnamon. 

Preparations  and  Doses. — Cinnamon- 
bark  (powdered),  ad  libitum. 

Cinnamon  powder,  compound,  10  to  30 
grains. 

Cinnamon-  (cassia)  oil,  1  to  3  minims. 

Cinnamon  extract,  fluid,  15  to  30  min- 
ims. 

Cinnamon  infusion,  60  to  120  minims. 

Cinnamon  tincture,  60  to  180  minims. 

Cinnamon  tincture,  compound,  30  to 
120  minims. 

Cinnamon  spirit  (essence),  10  to  30 
minims. 

Cinnamon  syrup,  1  to  2  drachms. 

Cinnamon-water,  ad  libitum. 

Cinnamic  acid,  ^/^  to  "/^  grain. 

Cinnamic  aldehyde,  not  employed 
medicinally. 

Cinnamyl-acetate,  not  employed. 

The  compound,  or  aromatic,  powder 
of  cinnamon  is  made  by  adding  35  parts 
of  ginger,  15  of  cardamom,  and  15  of 
nutrnofr,  to  35  parts  of  cinnamon. 

Physiological  Action. — Cinnamon  is  a 
warm  aromatic,  acting  as  a  true  sto- 
machic by  a  gentle  stimulating  action  on 


gastric  mucous  membrane,  increasing  its 
secretion  and  assisting  digestion;  hence 
its  general  employment  as  a  condiment. 
It  is  also  hajmostatic,  oxytocic,  and 
slightly  astringent.  The  oil  and  cin- 
namic acid  are  also  antiseptic,  and  the 
acid  is  claimed  to  be  antituberculotic:  a 
claim  not  altogether  satisfactorily  sub- 
stantiated. By  some,  cinnamon  is  held 
to  be  contra-indicated  in  all  inflam- 
matory states  of  the  gastro-intestinal 
tract. 

Therapeutics. — The  scope  of  the  drug 
is  not  a  very  extended  one,  and  it  is 
chiefly  employed  to  render  mixtures 
more  palatable. 

The  eclectics  generally  regard  cinna- 
mon a  powerful  specific  styptic:  a  claim 
that  appears  to  be  fairly  well  substanti- 
ated by  general  therapeutic  literature. 
It   certainly   has,    on   many    occasions, 
proved    most    efficacious    in    epistaxis, 
hfemoptysis,    hajmaturia,    and    uterine 
haemorrhage.    In  tedious  labors  depend- 
ent upon  atony  of  the  uterus  and  in- 
sufficiency   of    contractions,    cinnamon 
proved  quite  efficacious  in  the  hands  of 
Mursinna  and  Thomas  Hawkes  Tanner. 
This    drug    specifically    inlluences   the 
uterus,  controlling  lioBniorrhage  and  stim- 
ulating contraction  of  its  muscular  fibres. 
In  small  and  repeated  doses  it  is  capable 
of  producing  abortion;    hence  it  is  in- 
disputable that  it  exerts  a  powerful  in- 
fluence on  the  nutritive  functions  of  the 
womb.     It  is  possible  that  more  study 
and  e.xperimentation  will  reveal  the  drug 
to  be  possessed  of  further  remedial  virt- 
ues.    Webster   ("Dynam.  Therap.,"  '93). 
It  acts  upon  the  uterus  like,  though 
much   less   powerfiilly   than,   ergot,   and 
probably  also   on   the  smooth  muscular 
tissue  in  general — and  as  a  styptic  and 
astringent.    It  is  employed,  therefore,  as 
an  adjuvant  to  remedies  for  diarrhoea; 
in  the  second,  non-febrile  stage  of  acute 
intestinal  catarrh;  and  in  torpidity  and 
slight  hiemorrhages  of  the  uterus,  us\i- 
ally   in   combination   witli   ergot.     Roth 
("Mod.  Mat.  Med.,"  '95). 


CINNAMON.    THERAPEUTICS. 


203 


Though  used  as  an  aromatic,  its  chief 
use   is   to   control   uterine   hteraorrhage, 
and  it  acts  promptly  by  contracting  the 
bleeding  vessels;   it  is  also  of  consider- 
able value  in  some  forms  of  diarrhoea. 
Locke    ("Mat.  Med.  and  Therap.,"  '95). 
Thirty  cases  of  dysentery  were  perma- 
nently relieved  by  employing  from  one 
to  six  doses  of  the  Persian  remedy:   a 
drachm  of  powdered  cinnamon  made  into 
a  bolus  with  a  few  drops  of  water  and 
swallowed  with  as  little  fluid  as  possible. 
Avetoom    (Lancet,   Lond.,   vol.   i.   Mar., 
'95). 
As  AN  Antiseptic. — Cinnamon,  cin- 
namic  acid,  cinnamic  aldehyde,  and  the 
oil  of  cinnamon  doubtless  possess  anti- 
septic power,  and  may  be  advantageously 
used  in  the  treatment  of  purulent  foci 
and  necrotic  processes.     It  is  owing  to 
this  property  that  it  has   occasionally 
proved  of  some  value  in  pulmonary  tu- 
berculosis. 

No  living  disease-germ  can  resist  for 
more  than  a  few  hours  the  antiseptic 
power  of  essence  of  cinnamon;  even  its 
scent  will  kill  them.  The  essence  is  as 
effective  as  corrosive  sublimate.  An  in- 
fusion of  cinnamon  is  valuable  in  influ- 
enza, typhoid  fever,  and  cholera.  Chara- 
berland  (Med.  Age,  Apr.  25,  '94). 

Cinnamic  aldehyde,  or  cinnamic  acid, 
has  recently  been  employed  as  an  anti- 
septic in  the  various  forms  of  tubercu- 
losis, with  encouraging  results.  Stevens 
("Man.  of  Therap.,"  '94). 

The  oil  of  cinnamon  is  powerfully  anti- 
septic and  may  be  used  in  dilute  form  in 
the  dressing  of  wounds,  and  by  injection 
in  gonorrhoea;  in  the  latter  disease  it 
acts  best  in  the  early  stage.  Cinnamic 
acid  is  also  used  for  the  same  purpose. 
Hare   ("Prae.  Therap.,"  '94). 

A  solution  of  1  part  of  cinnamic  acid 
in  from  10  to  20  parts  of  glycerin  proves 
an  excellent  remedy  in  tuberculosis,  par- 
ticularly of  joint-cavities;  it  may  be 
injected  into  the  joint,  into  the  fungous 
mass,  or  into  the  gluteal  muscles.  Like- 
wise it  may  be  employed  in  pulmonary 
and  intestinal  tuberculosis.  Leucocytosis 
begins  in  from  nn  hour  and  a  half  to  two 
hours  after  the  injection,  and  reaches  the 


ma.ximum  in  eight  hours.  The  leucocytes 
are  increased,  and  there  is  no  decrease  in 
the  red  corpuscles  or  the  haemoglobin. 
Landerer  (Therap.  Monats.,  Feb.,  '94). 

It  is  probable  that  oil  of  cinnamon 
cures  consumption  in  two  ways:  In  the 
early  stage  of  catarrhal  phthisis  by  so 
directly  afi"ecting  the  bacilli  as  to  stop 
their  growth;  in  cases  farther  advanced 
by  only  allowing  organisms  incapable 
of  growth  to  pass  along  the  bronchi, 
and  thus  prevent  the  infection  of  fresh 
lobules.  In  this  way  the  disease  may  be 
limited  to  small  areas,  where  it  can  be 
dealt  with  by  the  vital  processes  of  the 
body,  and  cut  off  from  the  system  by 
the  formation  of  fibrous  tissue,  and  so 
cease  to  be  an  immediate  source  of 
danger.  It  is  interesting  to  observe  the 
order  in  which  the  symptoms  subside: 
The  expectoration  and  cough  are  the 
first  to  improve;  then  the  temperature 
tends  toward  the  normal;  finally  the 
weight  begins  to  increase;  and  all  these 
are  accompanied  by  gradual  diminution 
in  the  number  of  the  bacilli  in  the 
sputum.  Thompson  (Brit.  Med.  Jour., 
vol.  ii,  '97). 

In  advanced  cases  of  phthisis  personal 
results  with  cinnamic  acid  were  distinctly 
unfavorable.  In  12  cases  not  so  far  ad- 
vanced, treated  intravenously,  for  periods 
of  from  five  to  seven  weeks,  3  died,  I  be- 
came worse,  3  remained  in  much  the 
same  condition,  and  5  were  but  slightly 
improved.  Laryngeal  complications  were 
not  benefited  by  the  treatment.  Hremop- 
tysis  seemed  to  be  rendered  worse.  F. 
Friinkel  (Deutsche  Archiv  f.  klin.  Med., 
Ixv,  pts.  5  and  6,  1900). 

Febrile  Diseases. — In  low  stages  of 
fever,  and  where  there  is  persistent 
nausea  and  vomiting,  some  of  the  cin- 
namon preparations  appear  absolutely 
magical  in  effect,  but  the  causes  of  the 
latter  condition  are  so  varied,  and  fevers 
so  protean  in  their  aspects,  that  no  one 
remedy  can  be  relied  upon  on  all  occa- 
sions. 

It  has  been  recommended  in  malarial 
diseases,  but,  at  best,  it  can  only  be  con- 
sidered as  a  succedaneum. 


204 


CIRRHOSIS  OF  THE  LI-\T;K.    CLASSIFICATION. 


CIRRHOSIS  OF  THE  LIVER. 

Definition. — Suggested  by  Laennec  as 
a  name  for  one  particular  condition  of 
the  liver,  the  term  "cirrhosis"  was  not 
only  found  to  be  of  immediate  utility, 
but,  like  many  other  usefxil  words,  has 
rapidly  acquired  secondary  meanings, 
and  unfortunately  the  pathologist  and 
the  clinician  disagree  in  the  secondary 
meaning  which  they  assign  to  the  term. 
Hence  a  definition  of  "cirrhosis"  satisfac- 
tory to  all  parties  cannot  well  be  given. 
In  short,  the  word,  by  becoming  too  use- 
ful, threatens  to  outlive  its  usefulness. 
The  pathologist  employs  it  to  indicate 
all  those  conditions  in  which  there  is  a 
generalized,  as  opposed  to  localized  or 
focal,  development  of  increased  amounts 
of  fibrous  tissue  in  the  organ;  the  clini- 
cian recognizes  as  included  in  the  term 
all  those  conditions  characterized  by  con- 
nective-tissue overgrowth  in  connection 
with  the  liver,  whether  the  overgrowth 
be  focal  or  general,  whether  it  affect  the 
interior  of  the  organ  or  the  peritoneal 
capsule,  and  urges  in  favor  of  this  view 
that  all  these  conditions  may  give  rise 
to  a  like  series  of  symptoms;  while,  on 
the  other  hand,  he  is  unwilling  to  include 
under  the  terms  such  forms  of  connect- 
ive-tissue overgrowth  as  give  rise  to  no 
recognizable  symptoms.  According  to 
this  view,  the  gummatous  liver  of  tertiary 
syphilis  is  cirrhotic,  as  is  also  the  condi- 
tion of  chronic  productive  perihepatitis 
in  which  the  capsule  alone  is  affected, 
while  the  development  of  fibrous  tissue 
in  the  centres  of  the  lobules  which  may 
accompany  chronic  venous  congestion  of 
the  organ  is  not  to  be  classed  as  a  cir- 
rhosis. 

Remembering  that  Laennec  employed 
the  word  in  association  with  a  general- 
ized fibrosis  of  the  organ,  and  not  to  in- 
dicate the  complex  of  symptoms  induced 
by  this  condition,  and  recognizing,  also. 


that  it  is  impossible  to  restrict  it  nowa- 
days to  the  one  form  which  he  described, 
the  definition  accepted  by  the  patholo- 
gists more  nearly  approaches  the  original 
acceptation  of  the  term,  and  will  be  ad- 
hered to  in  this  article.  At  the  same 
time,  adequate  reference  will  be  made  to 
such  conditions  as  are  not  included  in 
that  definition,  but  which  are  regarded 
as  cirrhosis  by  a  large  number  of  clini- 
cians. 

Classification. — Starting,  then,  with 
this  definition,  and  including  under  the 
term  all  those  states  in  which  there  is  a 
generalized  overdevelopment  of  connect- 
ive tissue  throughout  the  liver,  it  will 
be  well,  before  attempting  any  classi- 
fication, to  pass  in  review  the  factors 
which  primarily  induce  this  overgrowth. 

Our  knowledge  of  the  causes  leading 
to  fibrosis  elsewhere,  imperfect  as  it  is, 
leads  to  the  belief  that  inflammation  is 
the  main  factor, — not  acute,  but,  as  it 
is  termed,  "productive."  It  may  be 
brought  about  by  the  action  of  a  mild 
Irritant  extending  over  a  relatively-long 
period,  or  by  the  recurrent  action  of  a 
somewhat  more  severe  irritant.  In  either 
case  there  is  a  stimulus  afforded  to  the 
proliferation  of  the  connective-tissue 
cells  of  the  part — and  the  new  growth 
corresponds  to  the  granulation-tissue 
seen  in  a  healing  exposed  wound.  A 
prominent  feature  in  fibroid  tissue  of  this 
nature  is  its  liability  to  contract.  It 
would  appear  that  in  the  commonest 
form  of  cirrhosis,  the  portal,  or  atrophic, 
this  is  the  main  process  at  work,  the 
irritant  reaching  the  liver  by  the  portal 
vein  and  especially  manifesting  its  ac- 
tivity by  sotting  up  an  irritation  along 
the  interlobular  l)ranchc8  of  that  vein. 

This,  however,  is  not  the  only  form  of 
inflarnniatory  fibrosis.  There  may  be  a 
now  development  of  connective  tisBuc — a 
replacement    fibrosis — to  take  the  ])!ace 


CIRRHOSIS  OF  THE  LIVER.    CLASSIFICATION. 


205 


of  cells  of  a  higher  order,  which,  through 
the  action  of  some  irritant  or  disturb- 
ance, have  undergone  destruction,  and 
it  is  still  a  matter  of  debate  whether,  in 
portal  cirrhosis  even,  such  replacement- 
fibrosis  is  not  largely  concerned  in  the 
new  gi-owth.  Of  more  recent  observers 
Sieveking,  examining  twenty  atrophic 
cirrhotic  livers  by  the  Van  Gieson 
method  of  staining,  concluded  that  the 
connective-tissue  growth  was  the  first 
disturbance.  Markwald  came  to  the  op- 
posite conclusion:  that  necrosis  of  the 
peripheral  liver-cells  is  the  first  event 
in  the  disease;  and  Euppert  describes 
both  productive  formation  of  connective 
tissues  and  inflammatory  atrophy  of  the 
liver-cells.  Personally  I  cannot  but  re- 
gard this  last  view  as  the  one  most  in 
harmony  with  the  appearances  seen  in 
the  majority  of  cases  of  well-defined 
portal  cirrhosis. 

In  one  form  of  cirrhosis, — the  pericel- 
lular or  interstitial, — of  which  in  man 
the  liver  of  congenital  syphilis  affords 
the  best  example, — replacement-fibrosis 
is  the  distinguishing  feature.  In  this 
the  various  stages  of  cellular  atrophy  can 
be  well  followed,  and  the  little  groups  of 
cells  are  to  be  seen  surrounded  by  del- 
icate new  tissues  of  a  character  very  dif- 
ferent from  that  of  the  dense  connective 
bands  seen  in  portal  cirrhosis.  The  dif- 
ference makes  itself  evidenced  by  the 
gross  appearance  of  the  organ,  for  this 
form  of  fibrous  tissue  does  not  contract, 
the  surface  remains  smooth,  and  the 
organ  is  enlarged  instead  of  being  dimin- 
ished in  size.  It  may  be  urged  that  this 
enlargement  is  a  proof  of  the  productive 
character  of  the  process,  but  the  enlarge- 
ment appears  to  be  due,  in  the  main,  to 
a  lack  of  pressure-atrophy  of  the  he- 
patic parenchyma  so  characteristic  of 
portal  cirrhosis,  coupled  with  a  com- 
pensatory proliferation  of  the  liver-cells 


to  replace  those  which  have  been  de- 
stroyed. A  proliferation  or  hypertrophy 
of  this  nature  is  occasionally  well  marked 
in  the  portal  form,  resulting  in  the  form- 
ation of  islands  of  new  liver-tissue  and 
the  production  of  a  large  hobnailed  liver. 
Rarely  the  new  growth  of  the  paren- 
chyma advances  to  an  adenomatous  or 
even  cancerous  condition,  and  we  meet 
with  a  greatly-enlarged  irregular  cir- 
rhotic liver  with  multiple  neoplastic 
masses  derived  from  the  liver-cells. 

If  this  process  be  the  explanation  of 
the  hypertrophied  liver  of  pericellular 
cirrhosis,  then  the  appearances  in  biliary 
cirrhosis  proper  present  macroscopically 
and  microscopically  so  many  points  of 
approximation  to  what  has  just  been  de- 
scribed, that  the  fibroid  overgrowth  here 
may  well  be  largely  of  the  nature  of  a 
replacement-fibrosis.  The  tendency  is 
for  recent  observers  to  regard  it  as  such, 
and  to  consider  that  biliary  cirrhosis  of 
the  type  which  has  especially  been  stud- 
ied by  Hanot  is  a  cholangitis  in  which 
either  the  bile-capillaries  within  the 
lobule,  or  the  cells  bordering  upon  these, 
are  especially  affected.  These  liver-cells 
undergo  gradual  atrophy  and  replace- 
ment by  new  connective  tissue.  Goluboff 
regards  this  form  as  being  primarily  due 
to  the  chronic,  diffuse,  catarrhal  angi- 
ocholitis  with  chronic,  diffuse  periangi- 
ocholitis. Now,  a  catarrhal  angiocholitis 
affecting  the  smallest  bile-ducts  affects 
the  capillaries  also,  and  is  inevitably  a 
process  affecting  the  liver-cells  them- 
selves. But,  while  accepting  these  views 
with  regard  to  the  main  characteristics 
of  the  fibroid  changes  of  these  two  im- 
portant forms  of  cirrhosis,  it  must,  I 
think,  be  admitted  that,  save  in  rela- 
tively-rare instances,  the  organs  affected 
by  one  or  other  form  of  the  disease  show 
a  mixture  of  both  productive  and  replace- 
ment chanjres. 


206 


CIRIIHOSIS  OF  THE  LIVER.     CLASSIFICATION. 


There  are  yet  other  ways  in  which 
fibroid  tissues  may  be  developed  in  vari- 
ous organs  ^vithout  recognizable  iniiam- 
matory  disturbance,  and,  as  I  have 
pointed  out  in  the  Middleton  Goldsmith 
Lectures  (1S96),  there  may  be  increased 
development  of  fibrous  tissue  of  a  func- 
tional type.  Such  fibrosis  is  to  be  recog- 
nized in  connection  with  altered  condi- 
tions of  the  arterial,  venous,  and  lym- 
phatic circulation.  It  is  difficult  to  say 
how  far  such  forms  manifest  themselves 
in  the  liver.  On  the  whole,  the  evi- 
dence is  against  there  being  any  exten- 
sive development  of  new  connective  tis- 
sue in  the  organ  from  such  a  cause;  but 
it  may  well  be  that  the  indurative  form 
of  passive  congestion  of  the  organ  and 
the  growth  of  fibrous  tissue  around  the 
interlobular  branches  of  the  hepatic  vein, 
in  eases  where  there  is  long-continued 
obstruction  of  moderate  degree  brought 
about  by  either  heart  or  lung  disease,  are 
to  be  regarded  as  due  to  a  laying  down 
of  new  connective  tissue  around  the  he- 
patic venules  of  non-inflammatory  origin. 

It  is  evident  that,  inasmuch  as  our 
definition  is  based  upon  the  one  condi- 
tion of  overdevelopment  of  fibrous  tissue 
in  the  organ,  a  proper  classification  of 
the  various  forms  of  cirrhosis  cannot  be 
based  primarily  or  adequately  upon  the 
disturbances  occurring  in  other  parts  of 
the  body  as  secondary  results  of  the  he- 
patic fibrosis,  but  must  be  either  etiolog- 
ical and  made  dependent  upon  the  vari- 
ous causes  leading  to  the  development 
of  fibrous  tissue  or,  on  the  other  hand, 
must — anatomically — be  determined  by 
the  parts  of  the  liver  which  are  the  pri- 
mary seat  of  the  development  of  the  new 
tissue.  Our  knowledge  of  these  cirrhoses 
is  still  insufficient  for  either  the  etio- 
logical or  the  anatomical  classification 
to  be  ideally  perfect.  Against  the  etio- 
logical classification  it  may  be  objected 


that  we  are  still  uncertain  as  to  how  far 
the  commonest  form — portal  cirrhosis — 
is  due  to  the  direct  action  of  alcohol,  how 
far  it  is  due  to  the  absorption  of  toxic 
substances  from  the  intestinal  canal  sec- 
ondary to  the  gastritis  and  enteritis  in- 
duced by  alcohol;  nor  again  does  the 
mere  enumeration  of  causes  help  us  in 
every  case  to  distinguish  the  special  type 
of  cirrhosis  which  those  causes  induce, 
and  so,  the  sjTnptoms  depending  upon 
the  form  of  hepatic  disturbance,  such  a 
classification  can  be  of  little  clinical 
value. 

On  the  other  hand,  the  anatomical 
classification  is  imperfect  to  the  extent 
that,  while  the  disease  may  begin  by  af- 
fecting one  special  portion  of  the  liver, 
as  the  process  of  fibrous-tissue  develop- 
ment extends,  it  involves  many  other 
parts,  and,  consequently,  in  well-devel- 
oped cases  cirrhosis  is  anatomically  of  a 
mixed  type,  and  it  is  far  from  easy  in 
such  cases  to  determine  how  the  condi- 
tion originated.  The  fullest  etiological 
classification  is  that  given  by  ChauSard, 
and  this  has,  at  the  same  time,  the  ad- 
vantage of  being  anatomical.  He  di- 
vides the  cirrhoses  as  follows: — 

1.  Vascular  (originating  around  the 
vessels). 

IA\  Tovip    S^-  Due  to  iiiKCStea  poisons. 

(yi)  lo.xii,    j. 2.  Due  to  autoclitlioiious  poisons. 

(a)  Local 


(B)  Infectious 


'1.  Hy  tlie  (lirool;  nv.- 
lioii  of  microboH. 
2.  liy  tliuir   indirect 
.action     till" on  rIi  - 
tlieir  toxiiia  (or,  :is 
he  tornm    it,  toxi- 

^     infection). 

<,  \.  Arteriosclerotic. 

RoBtive. 


(i))Ext™- 
tiopatic. 


(C)  Dystuopiiio  ! 

2.  Biliary. 

(A)  Dub  to  Diliaky  Retention, 

(B)  Dure   TO   ANOiociior.iTis   ok   tiiic  Smai.leu 

lill.K-DUCTS. 

3.  Capsulah. 

(A)  CiiiioNio  Localized  Periiiei-atitis. 

(/?)    CHUONIO   aENEUAI.IZEI)    PEUITONITIS. 

Admirable  as  is  this  classification,  it 


CIRRHOSIS  OF  THE  Ll\  KK.     PORTAL  CIRRUOSIS.     ETIOLOGY. 


207 


is  difficult  to  see  how  we  are  to  make  the 
distinction  which  is  here  made  between 
the  toxic  cirrhosis  and  the  toxi-infective. 
Anatomically  and  clinically,  poisons — 
whether  absorbed  from  the  stomach  or 
developed  in  the  system  itself,  or  again 
passing  into  the  blood  as  a  result  of  the 
growth  of  micro-organisms,  or  again 
given  off  by  micro-organisms  within  the 
liver  itself — may  produce  similar  lesions 
in  the  liver,  and  as  a  consequence  bring 
about  closely  allied,  if  not  identical,  ana- 
tomical changes  in  the  organ  with  the 
development  of  like  symptoms.  The  dis- 
tinction thus  raised  by  Chauffard  be- 
tween these  various  forms  is  too  fine  for 
practical  use;  clinically,  his  subdivisions 
are  almost  valueless;  hence,  in  this  ar- 
ticle, I  have  divided  the  cirrhoses  accord- 
ing to  anatomical  grounds  alone,  and 
shall  recognize  the  following  forms  of 
cirrhosis  according  to  the  origin  of  the 
process: — 

1.  PoBTAL  CIRRHOSIS,  in  which  the 
process  appears  to  begin  especially 
around  the  branches  of  the  portal  vein. 

2.  BiLiART  Cirrhosis. — (a)  In  which 
the  process  manifests  itself  around  the 
larger  bile-ducts.  (6)  In  which  the  proc- 
ess more  especially  shows  itself  around 
the  smallest  bile-ducts  and  in  connection 
with  the  bile-capillaries. 

3.  Pericellul.\r  cirrhosis,  charac- 
terized by  the  development  of  fibrous  tis- 
sue throughout  the  lobule  around  the 
individual  cells  and  groups  of  cells. 

4.  Arterial  cirrhosis,  in  which 
are  chronic  periarteritis  and  develop- 
ment of  fibrous  tissue  around  the  ar- 
teries. 

5.  Centrtlobular  cirrhosis,  char- 
acterized by  the  development  of  fibrous 
tissue  around  the  interlobular  branches 
of  the  hepatic  vein. 

6.  Secondary,  or  cextripetal.  cir- 
rhosis, due  to  the  extension  inward  of 


a  chronic  fibroid  inflammation  secondary 
to  chronic  productive  perihepatitis. 

7.  Sporadic  cirrhosis,  secondary  to 
focal  necroses  scattered  through  the 
organ  or  to  the  development  of  inflam- 
matory foci  in  no  one  well  defined  por- 
tion of  the  liver-tissue,  which  act  as 
centres  from  which  there  radiates  a 
fibroid  change. 

Of  these  different  forms  it  must  be 
repeated  that  all  are  not  clinically  recog- 
nizable and  that  it  must  be  clearly  borne 
in  mind  that  a  change  beginning  in  one 
anatomical  region  of  the  organ  is,  by  its 
extension,  peculiarly  liable  to  affect  other 
regions.  I  will  now  proceed  to  consider 
these  various  forms,  calling  attention  to 
those  which  are  clinically  important  and 
those  which  are,  up  to  the  present  time, 
clinically  unrecognizable. 

Portal  Cirrhosis. 

Etiology. — This  form  of  cirrhosis  is 
most  frequently  associated  with  alcohol- 
ism, more  especially  with  the  use  of 
spirits,  and  as  a  consequence  has  become 
known  in  England  as  the  gin-drinker's 
liver.  At  the  same  time  a  small  propor- 
tion of  cases  is  met  with  in  which  there 
is  an  entire  absence  of  the  alcoholic  his- 
tory. 

Upon  this  continent  all  other  causes 
are  insignificant  when  compared  with 
the  one  prime  cause  of  excessive  and 
long-continued  use  of  alcohol. 

Wliile  this  is  the  case  and  while  alco- 
hol must  be  regarded  as  a  prime  cause, 
much  evidence  has  accumulated  of  late 
years  to  throw  doubt  upon  alcohol  as  the 
primary  cause.  As  Pa}Tie  has  pointed 
out,  cirrhosis  of  the  liver  is  the  exception 
and  not  the  rule  in  autopsies  upon  drunk- 
ards; the  fatty,  and  not  the  cirrhotic, 
liver  is  typical  of  alcoholism.  Besides 
this,  the  experiments  of  a  large  num- 
ber of  observers  have  failed  to  demon- 
strate that  ethylic  and  not  amylic  alcohol 


208 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.     ETIOLOGY. 


is  capable  of  producing  any  marked  de- 
velopment of  cirrhosis  in  the  livers  of 
rabbits,  dogs,  pigs,  or  rats.  In  fact,  only 
three  observers,  Straus  and  Blocq  in  the 
rabbit,  and  de  Eechter  in  the  dog  and 
rabbit,  have  observed  such  cirrhotic 
changes.  Magnan,  Euge,  Pupier  Xairet, 
Combemale,  Strassmann,  Afanassijew, 
von  Kahlden,  Lafitte,  and  Kerr  have 
found  almost  entire  absence  of  portal  in- 
flammation, but  have  noticed  more  or 
less  extensive  fatty  infiltration  and  fatty 
degeneration. 

It  may  be  urged  that  these  observers 
did  not  preserve  their  animals  for  a  suf- 
ficient length  of  time;  nevertheless,  sev- 
eral of  the  observers  kept  their  animals 
for  several  months,  and,  were  alcohol 
the  direct  cause  of  the  disease,  there 
should  undoubtedly  have  been  more  evi- 
dence of,  at  the  least,  a  beginning  in- 
flammation in  the  portal  sheaths  around 
the  lobules. 

Importance  of  alcohol  is  much  over- 
rated in  the  etiology  of  cirrhosis  of  the 
liver.  Eosenstcin  (Brit.  Med.  Jour.,  Oct. 
1,  -OS). 

Alcohol,  in  the  main,  leads  to  fatty 
liver,  while,  on  the  other  hand,  the  evi- 
dence has  steadily  accumulated,  notably 
in  India,  that  extreme  cirrhosis  may 
attack  children  and  adults  who  have 
never  taken  a  particle  of  alcohol  either 
medicinally  or  otherwise.  J.  George 
Adami  (Lancet,  Aug.  13,  '98). 

To  ascertain  what  influence  alcohol 
had  as  a  cause  of  hobnailed  liver  the 
records  of  2020  necropsies  made  at  the 
Middlesex  Hospital  were  examined;  of 
these,  149  were  cases  of  cirrhosis  of  the 
liver,  which  was  hobnailed  in  30.  Of  the 
30  cases,  alcoholism  was  acknowledged 
in  15,  denied  in  9,  and  not  noted  in  lH. 
Of  4278  necropsies  made  on  children 
under  12  years  of  age  at  Great  Ormond 
Street,  there  were  23  eases,  and  hobnail- 
ing was  present  in  13.  Conclusions  are 
that  alcohol  plays  an  important  part  in 
the  prodiietion  of  cirrhosis,  but  in   wliiit 


way     is     uncertain.       Arthur     Voslcker 
(Brit  Med.  Jour.,  Sept.  29,  lilOO). 

This  discrepancy  between  the  experi- 
mental results  and  the  history  given  in 
man  of  alcoholism  is  to  be  explained  in 
two  ways:  Either  it  must  be  admitted 
that  alcoholism  is  the  primary  factor  in 
cirrhosis,  in  which  case  it  has  to  be  ac- 
knowledged that  individual  predisposi- 
tion plays  a  part  of  almost  equal  impor- 
tance; so  that  cirrhosis  is  to  be  described 
as  being  due  to  the  fibrotic  or  cirrhotic 
diathesis  manifesting  itself  under  the  in- 
fluence of  alcohol.  Or,  on  the  other 
hand,  we  must  regard  alcohol  purely  as 
a  predisposing  cause,  and  must  pass  be- 
yond the  alcoholism  and  admit  that,  at 
most,  alcohol  causes  irritation  and  in- 
flammation of  the  gastric  intestinal  mu- 
cosa, whereby  either  toxic  substances  pass 
into  the  portal  blood  from  the  intestines 
(and  regard  these  toxic  substances  as  the 
direct  cause  of  the  inflammatory  condi- 
tion of  the  organ),  or  it  is  possible  to 
go  further  and  regard  the  inflammation 
as  set  up  by  some  form  of  micro-organism 
entering  tlie  liver  along  the  same  paths. 
Upon  the  whole,  the  toxic,  as  opposed 
to  the  direct  alcoholic,  view  would  appear 
to  be  the  more  correct. 

All  recent  work  appears  to  be  leading 
to  the  conclusion  that  portal  cirrhosis 
of  the  liver  is  brought  about  by  a  condi- 
tion of  toxicJEmia.  Of  special  interest  in 
this  connection  is  the  observation  of 
Flexncr,  who  found  that  by  injecting  a 
1-per-eont.  solution  of  dogs'  serum, 
which  had  been  kept  for  twenty-four 
hours,  into  the  vein  of  a  rabbit,  the  ani- 
mal showed  almost  immediate  evidences 
of  profound  blood  disturbance  in  the 
shape  of  hfcmoglobinuria,  and  in  a  week 
began  to  lose  weight,  and,  dying  at  the 
end  of  the  second  week,  presented  in  its 
liver  most  marked  evidences  of  begin- 
ning porlal  oirrliosis. 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    ETIOLOGY. 


20S 


This  view  that  cirrhosis  is  the  result 
of  an  intoxication  following  gastro-in- 
testinal  disturbance  is  that  held  by  Hanot 
and  the  majority  of  recent  French  work- 
ers. 

[L6vi  has  gone  so  far  as  to  suggest  that 
the  condition  may  be  set  up  directly  by 
bacteria.  In  a  case  of  a  young  male  of 
17,  in  whom  he  found  periportal  cirrhosis 
and  greatly  enlarged  spleen,  with,  in 
addition,  bacterial  endocarditis  of  the 
pulmonary  valve,  albuminuria,  and  sup- 
purative meningitis,  he  discovered  a 
diplococous  pathogenic  in  guinea-pigs. 
From  liis  description,  the  cirrhosis  was  of 
a  rather  mi.xed  type,  for,  along  with  the 
■  ricli  connective-tissue  overgrowth,  there 
was  \vell-marked  proliferation  of  bile- 
canalieuli  directly  connected  with  the 
liver-cells.  The  condition  lasted  for  fifty- 
one  days,  and,  while  it  is  possible  that 
such  extensive  cirrhotic  changes  might 
have  been  produced  in  this  time,  the 
other  lesions  make  it  doubtful  whether 
he  was  dealing  with  a  condition  of  cir- 
rhosis directly  due  to  the  micro-organ- 
ism; certainly  it  cannot  be  said  that  the 
case  is  one  of  ordinary  cirrhosis.  J. 
Geobge  Adami.] 

The  following  facts  are  recorded  in 
regard  to  cirrhosis  of  the  liver:  1.  That 
in  at  least  a  very  large  number  of  well- 
marked  cases  of  progressive  cirrliosis  in 
man  there  is  to  be  found,  largely  within 
the  liver-cells  and  also  in  the  lymph- 
spaces  in  the  newly-formed  connective 
tissue,  a  peculiar  and  very  minute  form 
of  micro-organism,  presenting  on  staining 
to  the  proper  extent  the  form  of  a  diplo- 
cocous, surrounded  by  a  faint  halo,  or, 
when  stained  deeply,  being  a  rather  ob- 
scure ovoid  bacterium,  which  may  easily 
be  mistaken  for  stained  deposits  within 
the  cells.  2.  That  in  the  infective  cir- 
rhosis of  cattle  a  very  similar  micro- 
organism is  recognizable,  present  in  like 
positions  within  the  tissues  and  showing 
similar  appearances  when  stained.  3. 
That  from  at  least  thirty  cattle  affected 
with  this  disease  the  author  has  been  able 
to  isolate  the  micro-organism  from  the 
liver-bile,  abdominal  lymph-glands,  and 
in  some  cases  from  the  various  organs  in 


2—14 


the  body.  4.  That  the  micro-organism 
isolated  from  these  cattle  is  a  polymor- 
phous micro-organism,  appearing  as  a 
small  diplocoocus  when  grown  upon 
broth,  and  tends  to  assume  a  distinctly 
bacillary  form  when  grown  on  solid 
media.  5.  That  this  micro-organism  is 
pathogenic  for  the  animals  of  the  labora- 
tory, and  that  in  them  it  is  to  be  recog- 
nized within  the  hepatic  cells  as  in  other 
regions.  G.  That  from  a  case  of  distinct 
atrophic  cirrhosis  in  the  human  being  the 
author  has  been  able  to  isolate  from  vari- 
ous organs  of  the  body  a  similar  micro- 
organism, which,  grown  on  broth,  has  a 
diplococcic  form  and  grown  upon  agar 
is  present  as  a  short  or  longer  bacillus 
according  to  the  age  of  growth.  The 
author  does  not  believe  that  the  micro- 
organism causes  only  cirrhosis,  and  sug- 
gests that  it  may  be  the  cause  of  more 
than  one  disturbance  in  the  liver, — in- 
deed, in  other  organs.  J.  George  Adami 
(Lancet,  Aug.  13,  '98). 

On  the  other  hand,  the  not-infrequent 
presence  of  inflammation  surrounding 
the  atrophic  liver  and  the  frequent  pres- 
ence of  a  right-sided  pleurisy  (which  is 
suggestive  of  an  extension  of  the  inflam- 
matory process  through  the  diaphragm 
into  the  pleural  cavity)  make  it  not  im- 
possible that  some  cases,  at  least,  of  portal 
cirrhosis  are  due  to  something  beyond  the 
action  of  toxins  and  irritants  conveyed 
by  the  blood,  and  makes  it  probable  that 
some  cases  are  associated  with  the  pres- 
ence of  definite  bacteria. 

Besides  these  toxins,  whetlier  elabo- 
rated in  the  intestinal  canal  and  absorbed, 
or  due  to  the  groii-th  in  the  system  of 
bacteria,  other  poisonous  substances  may 
lead  to  the  developing  of  cirrhosis. 

Of  such  absorbed  toxins  it  has  been 
suggested  by  Budd  that  the  frequent  cir- 
rhosis found  in  the  natives  of  India,  who 
never  partake  of  alcohol,  is  secondary  to 
the  irritation  and  gastritis  produced  by 
highly-seasoned  foods;  and  Segers  de- 
scribes an  atrophic  form  in  the  Terra 


210 


CIRRHOSIS  OF  THE  M'STER.    POKTAL  CIRRHOSIS.    PATHOLOGY. 


del  Fuegians  brought  about  by  eating 
mussels.  He  obtained  from  these  mus- 
sels a  poison  which  was  definitely  toxic 
for  dogs  and  rabbits.  Such  cirrhosis  is 
not  infrequent  in  lead  poisoning,  and 
Lafitte  states  that,  giving  lead  to  rabbits 
with  their  food,  he  induced  a  cirrhotic 
condition  in  their  livers.  Eichhorst's 
case  of  nodular  cirrhosis  due  to  chronic 
phosphorus  poisoning  would  come  under 
the  same  category. 

Cirrhosis  of  the  liver  manifested  among 
the  Fuegians,  who  eat  from  12  to  25 
pounds  of  mussels  daily,  whether  good  or 
bad.  The  mussels  are  toxic  only  at  a 
certain  period  of  their  development;  the 
toxic  efTect  is  not  due  to  microbes,  but 
to  some  chemical  product.  Chronic  mus- 
sel poisoning  is  curable  up  to  a  certain 
point,  when  it  is  manifested  only  by  en- 
largement of  the  liver.  AVhen  it  has  ar- 
rived at  its  second  period,  that  of  atro- 
phic cirrhosis,  it  is  rapidly  fatal.  Segers 
(La  Sem.  M6d.,  Nov.  4,  '91). 

All  these  are  cases  of  disease  possess- 
ing a  similar  character,  namely:  charac- 
terized by  the  development  of  the  in- 
flammatory new  tissue  in  the  portal 
sheaths  and  more  especially  around  the 
branches  of  the  portal  vein.  For  the 
present  time  I  leave  out  of  account  the 
other  forms  of  cirrhosis  which  are  of  a 
different  type  brought  about  by  other 
toxic  agents  and  the  consequent  develop- 
ment of  inflammatory  foci  or  focal  ne- 
croses irregularly  scattered  through  the 
liver-substance. 

Neither  drugs,  —  O.IJ.,  alcohol,  phos- 
phorus, etc.,  —  nor  embolism  of  the 
portal  vein,  nor  ligature  of  the  hepatic 
artery  or  bile-duct,  or  other  operative 
procedure,  nor  acute  yellow  atrophy,  nor 
long-standing  venous  congestion,  can 
produce  a  true  hepatic  cirrhosis.  One  or 
other  of  these  causes  might  result  in 
cellular  degeneration  or  necrosis.  Such 
necrotic  foci  might  come  to  be  incap- 
sulated  by  fibrous  tissue,  but  this  is  not 
a  cirrhOHiH,  which,  in  the  proper  sense 
of  the  term,  is  a  progressively-advanc- 


ing interstitial  hepatitis.  The  same  ob- 
jection obtains  as  regards  the  interstitial 
changes  which  are  seen  passing  inward 
from  the  capsule  as  a  sequel  to  long- 
standing and  progressive  cases  of  fibrous 
perihepatitis.  There  is  marked  differ- 
ence between  the  cin'hotic  changes  that 
follow  upon  parenchymatous  degenera- 
tion and  the  tiue  classical  interstitial 
hepatitis,  which  arises  as  a  primary  con- 
dition. Siegenbeek  von  Heukelom  (Zeig- 
ler's  Beitrage,  B.  20,  H.  2,  No.  221,  '9l3). 
In  venous  cirrhosis  of  the  liver,  with- 
out any  lesion  of  the  biliary  apparatus 
or  of  the  pancreas,  the  insufficient 
emulsification  of  the  fats  points  to  a  dis- 
turbance in  the  functions  of  the  liver, 
while  the  ureogenic,  biligenic,  glycogenic, 
and  antitoxic  functions  of  the  liver  are 
not  yet  disturbed.  Luigi  Ferranini  (Ri- 
forma  Medica,  Oct.  31,  1900). 

Age  and  Sex. — With  regard  to  sex,  the 
condition  affects  males  more  than  twice 
as  frequently  as  it  does  females;  indeed, 
some  authorities  would  make  it  as  much 
as  three  times  more  frequent  in  males. 
From  the  more  recent  statistics  of  EoUes- 
ton  and  Fenton,  and  of  Kelynack,  it 
would  appear  that  the  most  common  age 
at  which  death  occurs  is  between  40  and 
50;  two-thirds  of  the  fatal  cases  occur 
between  35  and  50.  Kolleston  gives  the 
average  age  in  males  having  an  alcoholic 
history  as  48,  without  alcoholic  history, 
49,  and  in  females  4G  and  51,  respect- 
ively. Kelynack  gives  the  average  of 
his  121  cases  as:  males,  45J;  females,  42. 
But  the  condition  may  develop  at  almost 
any  period  of  life;  numerous  cases  have 
now  been  brought  forward  in  children 
since  Palmer  Howard  ptiblished  his  clas- 
sical article  on  this  subject. 

Pathology. — In  alcoholics,  in  whom 
the  condition  most  frequently  develops, 
the  liver  is,  at  first,  large,  owing  to  the 
fatty  infiltration  and  hepatic  congestion, 
both  of  which  are  the  direct  result  of  al- 
coholism. In  what  is  taken  to  be  the 
earliest  stage  there  is  observable  an  ab- 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.     PATHOLOGY. 


211 


normal  collection  of  small,  round  cells 
infiltrating  the  portal  sheaths  and  caus- 
ing them  to  stand  out  prominently  in  the 
stained  sections,  the  greatest  accumula- 
tion being  in  the  neighborhood  of  the 
vessels  running  in  those  perilobular 
sheaths.  These  small  cells  have  rounded, 
and  not  polymorphous,  nuclei,  and  are 
generally  regarded  as  being,  in  the  main, 
embryonic,  connective-tissue  cells.  In 
somewhat  more  advanced  conditions  the 
sheaths  have  undergone  definite  enlarge- 
ment and  are  formed  of  dense,  fibrous 
tissue,  although  there  is  still  an  abundant 
infiltration  of  small,  round  cells  more  es- 
pecially at  the  margins  where  they  abutt 
upon  the  lobular  parenchyma.  Just  as 
at  the  beginning  the  infiltration  is  not 
evenly  distributed  around  the  lobules,  so 
in  more  advanced  conditions  the  develop- 
ment of  fibrous  tissue  is  not  even,  and 
as  a  consequence  the  newly-formed  bands 
of  fibrous  tissue  tend  to  surround 
many  lobules;  the  fibrosis  is  what  is 
termed  muUilohular.  As  this  inflam- 
matory new  connective  tissue  reaches 
maturity,  it  contracts  and  by  its  shrink- 
age is  produced  the  nodular  and  hob- 
nailed surface  of  the  organ.  In  regions 
or  cases  in  which  this  process  of  connect- 
ive-tissue formation  has  reached  its  limit 
or  is  not  progressing,  the  new  bands  are 
sharply  defined  from  the  included  paren- 
chyma of  the  organ;  where  it  is  continu- 
ing to  advance  there  is  not  the  same 
sharp  separation;  small  groups  of  liver- 
cells  at  the  periphery  of  the  lobules  may 
be  seen  more  or  less  surrounded  by 
strands  of  newly-forming  fibrous  tissue 
and  exhibiting  well-marked  signs  of 
atrophy. 

There  is  still  much  debate  as  to 
whether  of  necessity  the  first  stage  of 
portal  cirrhosis  is  characterized  by  en- 
largement of  the  organ,  and  some  recent 
writers,  including  Osier,  would  draw  a 


distinction  between  the  ordinary  atrophic 
and  the  fatty  cirrhotic  liver.  It  is  true 
that  patients  may  die  of  intercurrent 
disease  when  the  liver  is  still  enlarged 
and  fatty,  and  that,  on  the  other  hand, 
patients  may  only  exhibit  symptoms  of 
cirrhosis  when  the  organ  is  already  so 
contracted  as  to  be  scarcely,  if  at  all, 
palpable.  But,  taking  into  consideration 
the  direct  effects  of  alcoholism  and  call- 
ing to  mind  three  or  four  cases  in  which, 
by  good  fortune,  careful  notes  of  the  size 
of  the  liver  were  taken  during  the  months 
preceding  sj-mptoms  of  portal  obstruc- 
tion, I  cannot  but  uphold  the  view  that 
portal  cirrhosis  (where  associated  with 
alcohol)  has  a  preliminary  stage  of  he- 
patic enlargement.  Where  alcoholism  is 
not  intimately  connected  with  the  de- 
velopment of  the  condition  there,  such 
preliminary  enlargement  may  not,  of  ne- 
cessity, form  a  stage  in  the  development 
of  the  condition. 

Study  of  37  fatal  cases  of  cirrhosis  of 
the  liver.  Cirrhosis  with  enlargement, 
without  change  in  size,  and  with  diminu- 
tion in  size  are  equally  frequent.  The 
size  of  the  liver  is  increased  in  one-third 
of  the  eases.  The  male  sex  is  more  fre- 
quently alTected.  Cirrhosis  with  enlarge- 
ment is  more  common  in  younger  people, 
and  cirrhosis  with  atrophy  in  old.  The 
average  duration  of  symptoms  is  longer 
in  the  atrophic  cases.  The  duration  of 
symptoms,  however,  varies  within  wide 
limits  in  all  varieties.  Hcemorrhage  is  a 
not-infrequent  cause  of  death  in  all 
forms,  and  a  fatal  htemorrhage  may  be 
the  first  symptom,  even  in  the  hyper- 
trophic form.  An  alcoholic  history  was 
obtained  in  every  case  in  which  the  sub- 
ject was  investigated.  A  history  of  pre- 
vious malaria,  syphilis,  or  gall-stones  was 
occasionally  obtained,  but  in  none  did 
it  seem  of  etiological  importance.  Mors* 
(Boston  Med.  and  Surg.  Jour.,  Mar.  10, 
'98). 

In  ordinary  or  atrophic  hepatic  cir- 
rhosis the  pancreas  is  enl.irged,  though 
the  head  and  bodv  are  relatively  smaller 


212 


CEREHOSIS  OF  THE  LIVEK.    PORTAL  CIREHOSIS.    VARIETIES. 


than  the  tail.  The  enlargement  is  due 
to  well-formed  fibrous  tissue,  cirrhosis 
of  the  liver  radiating  out  from  the 
blood-vessels.  The  gland-cells  undergo 
fatty  and  pigmentary  degeneration.  The 
areas  of  cells,  Langherans's  islands, 
share  in  the  pigmentary  change. 

In  hypertrophic  biliary  (or  Hanot's) 
cirrhosis  the  pancreas  is  not  increased  in 
size  or  in  weight,  but  shows  a  very  in- 
timate fibrosis  of  an  embryonic  type 
spreading  out  from  the  ducts  of  the 
gland.  There  is  periduetular  fibrosis  and 
a  little  proliferation  of  the  epithelium 
lining  the  duets.  The  gland-cells  show 
fatty  degeneration.  In  cardiac  hepatic 
cirrhosis  the  condition  of  the  pancreas  is 
inconstant.  Lefas  (Archiv  G6n6r.  de 
Med.,  May,  1900). 

It  is  remarkable  how  extreme  may  be 
the  atrophy  of  the  organ  as  a  result  of 
this  fibroid  contraction.  Cases  are  on 
record  in  which  in  place  of  the  normal 
50  to  60  ounces  (1500  to  1800  grammes), 
the  organ  has  weighed  from  16  to  10 
ounces  and  even  less,  and  notwithstand- 
ing this  the  main  symptoms  of  the  dis- 
ease may  not  be  referable  to  the  dimin- 
ished activity  of  the  organ  so  much  as 
to  the  secondary  disturbances  of  the 
portal  circulation.  Despite  the  great  de- 
velopment of  contracting  fibrous  tissue 
around  the  lobules,  bile  may  yet  find  its 
way  from  the  bile-capillaries  into  the 
bile-ducts,  and  the  fibrous  bands,  instead 
of  appearing  to  be  anaemic,  appear  to 
possess  abundant  blood-capillaries.  Ob- 
struction there  is  to  the  portal  circu- 
lation, and  yet  these  capillaries  can  be 
easily  injected  from  the  portal  vein;  so 
that  it  is  not  necessary  to  assume,  as 
some  have  done,  that  the  blood-supply  of 
the  liver  in  this  form  of  cirrhosis  is,  in 
the  main,  conveyed  by  the  branches  of 
the  hepatic  artery.  As  a  result  of  the 
process,  the  organ  is  dense,  firm,  and 
of  almost  leathery  consistence,  present- 
ing, on  section,  minute  islands  of  red- 
dish-yellow parenchyma  of  varying  size 


surrounded  by  the  more  glistening  bands 
of  connective  tissue.  If  the  condition  be 
complicated  with  jaundice,  then  the  isl- 
ands of  liver-tissue  more  especially  are 
tinged  by  the  bile-pigment;  if  with 
hemochromatosis  (pigmental  cirrhosis), 
both  fibrous  and  liver-tissue  may  show  a 
darker,  slaty  tinge;  if  the  liver-cells  still 
retain  a  fair  amount  of  fat  the  islands 
of  parenchyma  appear  of  a  paler  yellow; 
if  the  process  has  been  of  more  acute 
development,  then  with  the  fibrosis  there 
may  be  inflammatory  congestion,  and 
the  organ,  in  general,  have  a  reddish  ap- 
pearance. 

In  general,  the  left  lobe  is  more  af- 
fected and  more  shrunken  than  the  right; 
sometimes  it  is  singularly  small, — a  mere 
appendage  to  the  larger  right  lobe;  but 
this  is  not  constantly  the  case,  and  the 
opposite  may  occur.  It  must  be  kept  in 
mind  that  the  right  lobe  may  be  con- 
tracted behind  the  ribs  and  the  left 
still  be  prominent:  a  condition  which 
has  more  than  once  led  to  the  mis- 
taken diagnosis  of  hepatic  or  pancreatic 
tumor. 

Tlic  anatomical  picture  presented  by 
a  cirrhotic  liver  is  usually  one  in  which 
tlie  regenerative  processes  are  the  most 
strilcing,   the   destructive   process   being 
sometimes   evident,   sometimes   entirely 
past  and  represented  only  by  the  wide- 
spread .scars.    Cin'hosis  of  the  liver  may 
be  deliniid  iis  a  chronic  disease  in  which 
destructive  processes,  probably  often  re- 
])eated,  result  in  a  loss  of  the  functional 
liver  tissue  immediately  followed  by  the 
furniation  of  a  scar,  the  healing  process, 
:iMd  later  by  an  attempt  at  the  restitu- 
tion of  the  liver  to  normal  by  regener- 
ative    processes.     W.     G.     MacCallura 
(.Jour.     Anier.     Med.     Assoc,     Sept.     3, 
1!)0I). 
Varieties  of  Portal  Cirrhosis. — Thus 
far  I  have  treated  of  portal  cirrhosis  in 
general,  but  it  must  be  recognized  that 
there  are  several  varieties  and  stages  in 
which  the  condition  may  manifest  itself. 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.     VARIETIES. 


213 


The  unfortunate  employment  of  the  term 
"atrophic"  has  led  to  not  a  little  confu- 
sion and  failure  to  recognize  that  these 
several  varieties  are  but  manifestations 
of  one  and  the  same  process. 

It  may,  in  the  first  place,  be  questioned 
whether  the  disease  always  presents  the 
same  slow  rate  of  development.  Appar- 
ently this  is  not  the  case;  we  may  have 
either  acute  or  chronic  cirrhosis.  The 
London  school  of  pathologists  is  inclined 
to  recognize  the  red  atrophic  liver,  char- 
acterized by  the  presence  of  large  islands 
of  yellow,  fattily-degenerated  paren- 
chyma surrounded  by  greatly-reddened 
congested  tissue,  which,  under  the  micro- 
scope, shows  abundant  signs  of  a  sub- 
acute productive  inflammatory  condition, 
■with  leucocytic  infiltration  and  the  de- 
velopment of  new  connective  tissue.  It 
is  still  a  matter  of  a  little  doubt  as  to 
whether  this  condition  is  truly  a  portal 
cirrhosis. 

The  cases  brought  forward  by  Cayley 
and  Carrington  and  others  all  appear  to 
be  of  this  nature.  There  is  a  history  of 
excessive  indulgence  in  alcoholism,  of 
preliminary  slight  gastric  disturbance 
with  signs  of  epigastric  oppression,  con- 
traction of  the  liver,  and  development  of 
ascites  accompanied  by  more  or  less  jaun- 
dice. The  gross  appearance  of  the  liver 
is  not  greatly  unlike  that  of  acute  yellow 
atrophy;  but  death  takes  place  not  in 
a  few  days  or  weeks,  but  in  two  or  three 
months  after  the  first  symptoms  are  com- 
plained of. 

On  the  whole,  therefore,  I  am  inclined 
to  classify  this  red  atrophy  as  an  acute 
condition  of  portal  cirrhosis. 

As  vrill  be  readily  understood,  the  vast 
majority  of  cases  are,  in  the  nature  of 
things,  chronic. 

Thus,  to  classify  the  different  varie- 
ties:— 

(A)  Acute:    Eed  Atrophy  of  the 


Liver.    This  condition  has  just  been  re- 
vie  v,ed. 

(B)  Chronic:  1.  Enlarged  Fatty 
Cirrhotic  Liver.  The  organ  is  mark- 
edly enlarged,  shows  but  slight  nodula- 
tion,  and  microscopically  presents  a  not- 
far-advanced  condition  of  cirrhosis.  In  a 
large  number  of  cases  it  is  unaccom- 
panied by  ascites,  although  the  spleen 
may  be  enlarged;  it  occurs  essentially  in 
alcoholics  and  may  not  be  recognized 
until  after  death  from  some  intercurrent 
disease. 

2.  The  Atrophic  Hobnailed  Livek. 
— The  characteristic  form  of  the  disease. 
The  organ  greatly  reduced  in  size,  with 
surface  studded  with  nodules  of  varying 
size,  generally  small;  very  dense  and 
leathery;  generally  accompanied  by 
marked  ascites  and  other  evidences  of 
portal  obstruction,  and  enlarged  spleen. 
On  section,  of  yellowish-red  color,  show- 
ing well-developed,  glistening  bands  of 
fibrous  tissue  separating  ofif  small  islands 
of  the  parenchjTna. 

3.  Portal  Cirrhosis  with  Second- 
art  Parenchymatous  Hypertrophy. 
— The  hypertrophic,  alcoholic  cirrhosis 
of  French  writers.  The  organ  larger 
than,  but  similar  in  character  to,  the 
preceding  form.  There  is  a  considerable 
amount  of  confusion  about  this  form, 
owing  to  the  use  of  the  term  'Tiy- 
pertrophic."  It  has  often  been  con- 
fused with  the  biliary  cirrhosis  of  the 
type  studied  more  especially  by  Hanot; 
while,  again,  others  confound  with  this 
the  intermediate  stage  between  the  en- 
larged fatty  cirrhotic  liver  and  the  small 
atrophic  organ,  and  again  cases  of  mixed 
biliary  and  portal  cirrhosis.  In  the  true 
hypertrophic  cirrhosis  of  this  type  the 
organ  presents  a  nodular  surface,  some 
of  the  nodules  being  of  a  relatively-large 
size.  The  weight  is  normal  or  above  the 
normal,  and  the  enlarged  size  appears  to 


214 


CIKKHOSIS  OF  THE  LIVEK.    PORTAL  CIERHOSIS.    VARIETIES. 


be  due,  in  the  main,  to  compensatory 
overgrowth  of  some  of  the  isolated  lobu- 
lar masses  and  to  a  partial  recovery  of  the 
organ  from  the  effect  of  the  cirrhosis. 

•i.  PoKTAL  Cirrhosis  with  Adenom- 
atous OR  Adexocarcixomatous  Over- 
growth.— The  distinction  between  the 
last  condition  of  cirrhosis  with  parenchy- 
matous h}T)ertrophy  and  cirrhosis  with 
generalized  adenomatous  condition  is 
very  subtle,  and,  as  shown  in  connection 
vrith  Fussell  and  Kelly's  first  case  (Trans. 
Assoc.  Amer.  Physic,  vol.  x,  p.  116,  '95), 
good  authorities  may  differ  as  to  whether 
a  liver  presents  the  one  or  the  other 
condition.  On  the  other  hand,  there  may 
be  such  extensive  overgrowth  and  multi- 
ple formation  of  large  neoplastic  masses, 
that  there  can  be  no  doubt  as  to  the  can- 
cerous nature. 

In  the  majority  of  these  cases  the  cir- 
rhosis seems  to  be  of  the  mixed  kind, 
being  multilobular  and  at  the  same  time 
presenting  abundant  formation  of  new 
bile-canaliculi:  an  indication  that  pos- 
sibly the  following  form  is  not  truly  a 
mixed  portal  and  biliary  cirrhosis,  but  a 
portal  cirrhosis  with  parenchymatous  hy- 
pertrophy, one  of  the  indications  of  their 
hypertrophy  being  a  proliferation  of  the 
bile-canaliculi. 

5.  Mixed  CiRRnosis. — A  very  large 
number  of  cases  must  anatomically  be 
classed  under  the  heading  of  mixed  cir- 
rhosis, thougli  the  gross  appearance  of 
the  organ  and  the  clinical  history  bring 
them  definitely  into  the  category  of 
portal  cirrhosis.  The  condition  is,  in 
the  main,  multilobular,  but  there  is 
abundant  formation  of  new  bile-canalic- 
uli. The  organ,  again,  in  general,  ap- 
proximates to  the  normal  size,  and  there 
is  not  the  extreme  atrophy  seen  in  the 
uncomplicated  cirrhosis. 

6.  Portal  Cinniiosis  with  Pigmen- 
tation.— It  is  well  known  that  normally 


the  liver  contains  a  certain  amount  of 
iron.  Lindemann  (Ctbl.  f.  AUgem. 
Pathol.,  vol.  viii,  "QT)  finds  that  this  iron 
in  the  slightest  grades  exists  only  in  the 
cells  of  the  portal  tissue;  when  more 
extensive,  there  is  deposit  of  the  iron-pig- 
ment in  the  capillarj'-walls,  and  Kupp- 
fer's  cells  are  affected;  in  the  highest 
grade  of  antemia  the  pigment  is  in  the 
liver-cells  at  the  periphery  of  the  acini. 
This  pigment  is,  in  general,  of  a  bro^vn- 
ish  or  ochrous  tint,  and,  though  Auscher 
and  Lapicque  (Soc.  Med.  des  Hop.,  Feb. 
12,  '97)  speak  of  it  as  a  form  of  hydrated 
iron,  it  is,  perhaps,  more  truly  an  iron 
albuminate.  Within  the  last  few  years, 
Letulle,  Hanot  and  Schuhmann,  Gilbert, 
and  Grenet  have  described  several  cases 
of  pigmentary  cirrhosis,  occurring  in  gen- 
eral in  association  with  the  hypertro- 
phic type  of  the  disease:  i.e.,  with  either 
mixed  cirrhosis  or  portal  cirrhosis  with 
parenchymatous  hypertrophy.  In  these 
cases  the  livers  contain  increased 
amounts  of  iron.  In  a  recent  case  of  this 
nature  observed  by  me  the  liver  was  of 
normal  weight,  but  diminished  in  size 
and  markedly  atrophic,  showing  this  iron 
everywhere,  not  only  in  the  portal  spaces, 
but  present  in  large  amounts  in  the  cells 
right  to  the  very  centre  of  the  hepatic 
lobules.  The  Germans  are  inclined  to 
consider  these  cases  as  examples  of  cir- 
rhosis complicated  with  the  condition 
which  von  Eecklinghauscn  has  denomi- 
nated "hfemochromatosis":  a  condition 
of  wliich  a  full  account  will  be  found  in 
Hintze's  paper  (Virchow's  Archiv,  vol. 
exxxix,  p.  459).  Two  out  of  five  of 
Hintze's  cases  of  this  condition  showed 
cirrhosis  of  the  liver. 

In  these  states  the  iron-pigment  is  not 
only  present  in  the  liver,  but  is  abundant 
more  especially  in  the  non-striated 
muscle,  more  especially  in  the  intestines, 
in  the  lymphatic  glands,  and  it  may  be 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    VARIETIES. 


215 


also  in  the  pancreas,  spleen,  salivary 
glands,  etc.  Lubarsch  {ibid.,  p.  495) 
ascribes  this  condition  either  to  second- 
ary results  of  large  haemorrhages  or  to 
the  development  of  multiple  capillary 
hffimorrhages  whereby  the  iron  of  the 
haemoglobin  is  taken  up  and  deposited 
in  this  modified  form  into  the  various 
organs.  Possibly  there  is  an  intimate 
connection  between  the  occurrence  of 
multiple  small  hsemorrhages  in  the  portal 
area  and  the  production  of  this  pig- 
mented cirrhosis;  rarely  the  skin  also  be- 
comes pigmented  and  shows  a  bluish 
color. 

[Bronzed  diabetes.  In  association  with 
diabetes  there  also  occurs,  rarely,  a 
combination  of  pigmentation  and  bronz- 
ing of  the  skin,  and  cirrhosis  of  the 
liver  of  the  "mixed"  portal  type.  The 
cases  of  this  diabHe  hronzi  have  been 
noted  almost  exclusively  in  France, 
though  Saundby,  in  England,  has  re- 
corded one  case.  In  many  cases  of 
diabetes,  more  especially  in  the  early 
stage,  the  liver  is  found  enlarged; 
Saundby,  indeed,  concludes  that  it  is 
generally  enlarged,  weighing  from  50  to 
60  ounces.  The  enlargement  is,  in  the 
main,  due  to  chronic  congestion,  but  a 
small  amount  of  interstitial  hepatitis  is 
frequently  present,  and  occasionally  this 
is  so  extensive  as  to  produce  distinct  cir- 
rhosis. In  such  cases  the  liver  is  some- 
times smooth,  at  other  times  it  is  found 
granular  and  scarred.  Brault  and  Gil- 
lard  are  of  the  opinion  that  the  new 
growth  begins  in  both  the  hepatic  and 
portal  areas,  by  which  I  infer  that  they 
would  indicate  that  the  process  is  of 
the  mixed  type.  The  accounts  given  in 
the  French  journals  are,  in  general,  so 
meagre,  that  it  is  difficult  to  arrive  at 
any  satisfactory  conclusions  as  to  the 
intimate  nature  of  the  pigmentation 
which  has,  at  times,  been  found  to  ac- 
company this  cirrhosis.  (For  another 
form  of  pigmental  cirrhosis,  the  "cir- 
rhosis arthracotica"  of  Welch,  see  later 
under  Sporadic  Cirrhosis.)  J.  George 
Adami.] 


Cirrhosis  with  pigmentation.  Series 
of  49  cases  of  atrophic  cirrhosis  of  the 
liver  (Laennec's)  treated  in  the  wards 
of  the  Johns  Hopkins  Hospital.  None 
showed  permanent  pigmentation.  Eight 
cases  of  hypertrophic  cirrhosis  of  the 
liver  were  also  studied,  and  one  of  these 
presented  bronzing  of  the  skin.  The 
clinical  analysis  made  by  Ansehutz,  who 
studied  24  cases  collected  from  the  liter- 
ature up  to  1899,  shows  that  the  symp- 
toms are  those  of  rapidly  fatal  diabetes 
mellitus  accompanied  with  cirrhosis  of 
the  liver,  commonly  of  the  hypertrophic 
variety.  The  pigmented  cirrhotic  liver 
is  found  at  autopsy.  This  pathological 
manifestation  was  found  in  23  out  of 
24  of  Anschutz's  cases;  in  all  but  I 
instance  the  liver  was  enlarged.  It  con- 
tained an  ochre-colored,  iron-containing 
pigment.  This  pigment  was  present  in 
the  liver-cells  and  in  the  connective  tis- 
sue. In  15  of  the  cases  there  was  also 
a  marked  increase  in  the  amount  of  the 
connective  tissue  of  the  pancreas,  and 
18  of  the  cases  revealed  pigmentation 
of  the  pancreatic  epithelium  and  con- 
nective tissue.  The  pigment  of  the  liver 
is  now  generally  believed  to  be  the  ex- 
citing cause  of  the  liver  changes.  Opie 
designated  this  pigmentation  of  the  liver 
and  pancreas  as  a  distinct  pathological 
entity,  and  the  term  hasmochromatoais 
should  be  used  to  designate  tliis  con- 
dition. The  conclusions  of  Opie  were  as 
follows:  "1.  There  exists  a  distinct 
morbid  entity,  hiemochromatosis,  char- 
acterized by  the  wide-spread  deposition 
of  an  iron-containing  pigment  in  certain 
cells,  and  an  associated  formation  of 
iron-free  pigments  in  a  variety  of  locali- 
ties in  which  pigment  is  found  in  mod- 
erate amount  under  physiological  con- 
ditions. 2.  With  the  pigment  accumula- 
tion there  is  a  degeneration  and  death 
of  the  containing  cells  and  the  conse- 
quent interstitial  inflammation,  notably 
of  the  liver  and  pancreas,  which  become 
the  scat  of  inflammatory  changes,  ac- 
companied by  hypertrophy  of  the  organ. 
3.  When  the  chronic  interstitial  pan- 
creatitis has  reached  a  certain  grade  of 
intensity,  diabetes  ensues  and  is  the 
terminal  event  in  the  disease." 

Report  of  a  personal  case  in  a  male 


216 


CIRRHOSIS  OF  THE  LI^-EK.    PORTAL  CIRRHOSIS.    SYMPTOMS. 


50  years  of  age.  The  skin,  particularly 
that  of  the  hands,  wrist,  and  the  legs, 
■was  deeply  bronzed.  The  liver  was 
markedly  enlarged,  and  the  urine  did 
not  contain  albumin  or  sugar,  but  gave 
a  reaction  for  indican  and  iron.  T.  B. 
Futcher  (Jour.  Amer.  Med.  Assoc,  Sept. 
2S,  1901). 

7.    ClEHHOSIS  WITH  CALCIFICATION. 

I  am  acquainted  with  only  one  well- 
marked  example  of  this  condition,  de- 
scribed by  Taggert  (Trans.  Path.  Soc. 
London,  '89),  in  which  the  deposit  of 
calcareous  matter  in  the  cirrhosed  liver 
was  so  extensive  that  a  saw  had  to  be 
used  in  order  to  make  sections  of  the 
organ. 

Symptoms.- — The  condition  of  portal 
cirrhosis  begins  insidiously  and  may  con- 
tinue to  an  extreme  condition  without 
producing  any  symptoms  which  call  at- 
tention to  the  existence  of  the  process. 
Very  frequently  the  earliest  symptoms 
are  associated  with  the  alimentary  tract; 
next  in  order  are  evidences  of  portal  ob- 
struction, and  only  when  the  condition 
is  very  well  marked  may  there  be  dis- 
turbances referable  to  the  hepatic  func- 
tion. \Vliether  the  gastric  and  intestinal 
disturbances  are  primary  or  secondary 
is  a  matter  concerning  which  there  has 
been  debate.  That  they  are  not  entirely 
due  to  the  overfilling  of  the  gastric  and 
intestinal  vessels  in  consequence  of  the 
portal  obstruction  is,  I  think,  evident 
from  the  fact  that  they  appear  long  be- 
fore any  signs  of  such  obstruction  show 
themselves,  and  if  we  ascribe  alcoholic 
cirrhosis  not  so  much  to  the  alcohol  itself 
as  to  the  pathological  condition  of  the 
stomach  and  intestines  whereby  toxic 
substances  are  absorbed  from  the  food, 
then  we  must  regard  this  as  being  the 
earliest  disturbance  in  the  course  of  the 
against  the  proper  performance  of  the 
disease.  That  at  a  later  period  the  ab- 
dominal   congestion    further    militates 


gastric  and  intestinal  functions  there  can 
be  no  doubt.  It  would  be  well,  there- 
fore, to  subdivide  the  symptoms  into: — 

1.  The  disturbances  occurring  in  con- 
nection with  the  alimentary  tract. 

2.  Symptoms  of  vascular  obstruction. 

3.  S}Tiiptoms  referable  to  disordered 
function  of  the  liver  and  to  altered 
metabolism. 

Symptojis  Referable  to  Gastric 
AND  Intestinal  Disturbance.  —  Of 
these  the  most  noticeable  are:  at  the  very 
earliest  stage  slight  dyspepsia,  morning 
vomiting  or  nausea,  and  furred  tongue; 
added  to  this  there  may  be  eructations 
and  irregularity  of  the  bowels.  There  is 
often  an  alternation  of  constipation  and 
catarrhal  diarrhoea.  During  the  former 
of  these  the  stools  often  present  remark- 
able modifications:  some  days  they  are 
normal,  then  they  become  very  dry  and 
are  covered  with  a  thick  layer  of  mucus; 
at  other  times  they  are  colorless,  and,  as 
Graves  has  pointed  out,  in  the  same  stool 
one  may  find  portions  which  are  gray, 
clayey,  and  others  of  normal  color.  To 
these  disturbances  of  the  digestive  system 
may  be  largely  attributed  the  emaciation 
of  the  later  stages  of  the  disease. 

Symptoms  Eeferable  to  Disturb- 
ances OF  THE  Circulation. — So  long  as 
there  is  a  well-established  collateral  cir- 
culation, for  so  long  will  there  be  no 
symptoms  referable  to  obstruction.  It  is 
only  when  this  collateral  circulation  be- 
comes inadequate  to  carry  the  portal 
blood  to  the  heart  that  ascites  and 
other  obstructive  disturbances  supervene. 
Thus,  not  infrequently  wo  moot  with  ex- 
tensive portal  cirrhosis  without  a  sign  of 
ascites.  Very  frequently,  however,  the 
nature  of  this  collateral  circulation  is  the 
direct  cause  of  death;  more  especially  is 
this  the  case  with  the  plexus  of  submu- 
cous veins  at  the  lower  end  of  the  oesoph- 
agus which  plays  a  prominent  part  in 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    SYilPTOMS. 


217 


this  collateral  circulation.  These  veins, 
being  practically  unsupported  toward  the 
free  surface  of  the  oesophagus,  become 
varicosed  and  relatively  enormous;  the 
patient  may  appear  in  very  fair  health 
and  the  liver  be  performing  its  functions 
satisfactorily  with  but  a  thirty-second  of 
an  inch  or  less  intervening  between  life 
and  death;  for  it  is  these  varicosed  sub- 
ccsophageal  veins  which  are  especially 
liable  to  rupture  and  to  produce  so  ex- 
treme a  hasmorrhage  that  death  follows 
in  the  course  of  a  few  hours. 

The  best  account  of  this  collateral  cir- 
culation is  given  by  Osier  and  we  here 
recapitulate  it: — 

"The  compensatory  circulation  is  usu- 
ally readily  demonstrated.  It  is  carried 
out  by  the  following  set  of  vessels:  1. 
The  accessory  portal  system  of  Sappey, 
of  which  important  branches  pass  in  the 
round  and  suspensory  ligaments  and 
\mite  with  the  epigastric  and  mammary 
systems.  These  vessels  are  numerous  and 
small.  Occasionally  a  large  single  vein, 
which  may  attain  the  size  of  the  little 
finger,  passes  from  the  hilus  of  the  liver 
in  the  round  ligament  and  joins  the  epi- 
gastric veins  at  the  navel.  Although 
this  has  the  position  of  the  umbilical 
vein,  it  is  usually,  as  Sappey  showed,  a 
para-umbilical  vein;  that  is,  an  enlarged 
vein  by  the  side  of  the  obliterated  um- 
bilical vessel.  There  may  be  produced 
about  the  navel  a  large  bunch  of  varices: 
the  so-called  caput  Medusae.  Other 
branches  of  this  system  occur  in  the 
gastro-cpiploic  omentum,  about  the  gall- 
bladder, and,  most  important  of  all,  in 
the  suspensory  ligament.  These  latter 
form  large  branches,  which  anastomose 
freely  with  the  diaphragmatic  veins,  and 
so  unite  with  the  vena  azygos.  2.  By  the 
anastomosis  between  the  oesophageal  and 
gastric  veins.  The  veins  at  the  lower 
end  of  the  oesophagus  may  be  enormously 


enlarged,  producing  varices  which  pro- 
ject on  the  mucous  membrane.  3.  The 
communications  between  the  haemor- 
rhoidal  and  the  inferior  mesenteric  veins. 
The  freedom  of  communication  in  this 
direction  is  very  variable,  and  in  some 
instances  the  hemorrhoidal  veins  are 
not  much  enlarged.  4.  The  veins  of 
Betzius,  which  unite  the  radicles  of  the 
portal  branches  in  the  intestines  and 
mesentery  with  the  inferior  vena  cava  and 
its  branches.  To  this  system  belong  the 
whole  group  of  retroperitoneal  veins, 
which  are,  in  most  instances,  enormously 
enlarged,  particularly  about  the  kidneys, 
and  which  serve  to  carry  off  a  consider- 
able proportion  of  the  blood." 

But  in  addition  to  the  disturbance  in 
the  portal  circulation,  there  appears  to 
be  also  a  frequent  accompanying  disturb- 
ance in  the  general  circulation.  It  may 
here  be  more  correct — inasmuch  as  this 
disturbance  seems  to  be  largely  associ- 
ated with  alterations  in  the  blood 
brought  about  by  the  hepatic  disturbance 
— to  refer  to  this  under  a  later  heading. 

Case  of  alcoholic  cirrhosis  in  which 
there  were  present  enlargement  of  the 
liver,  dilatation  of  the  subcutaneous  ab- 
dominal veins  and  ascites  (necessitating 
four  punctures  in  the  course  of  a  year). 
Small,  erectile,  venous  tumors  appeared 
on  the  face,  in  the  pharynx,  and  on  the 
internal  surface  of  the  last  phalanx  of 
the  ring-finger  of  the  left  hand.  The  lat- 
ter became  the  source  of  a  quite-active 
hemorrhage.  Bouchard  (Marseille-mfid., 
Oct.  15, '91). 

Ascites. — The  ascites  of  portal  cir- 
rhosis develops  gradually,  and  in  this  way 
is  to  be  distinguished  from  that  follow- 
ing thrombosis  of  the  portal  vein.  While 
it  is  a  very  prominent  and  characteristic 
sjTnptom  of  the  condition,  it  must  be 
remembered  that  it  is  far  from  being 
constantly  present.  Indeed,  I  may  go 
further   and   point   out  that   much   of 


21S 


CIRRHOSIS  OF  THE  LR'EK.    POKTAL  CIRKHOSIS.    SYIMPTOMS. 


the  failure  of  clinicians  to  recognize 
portal  cirrhosis  is  due  to  the  erroneous 
belief  that  ascites  almost  constantly  de- 
velops. It  does  not  hij  any  means;  only 
in  advanced  atrophic  cases  is  it  the  rule. 
The  older  writers  speak  of  it  as  being 
present  in  about  80  per  cent,  of  the  cases; 
more  recent  careful  observers  give  a 
lower  proportion,  thus:  Eolleston  and 
Fenton  (Birmingham  Med.  Eeview,  Oct., 
'96)  find,  from  the  post-mortem  records 
at  St.  George's  Hospital  in  London,  that 
of  114  cases  only  36,  or  a  little  over  30 
per  cent.,  showed  ascites.  Kelynack  in 
121  examples  {ibid.,  Feb.,  '97)  of  com- 
mon hepatic  cirrhosis,  as  he  terms  it, 
coming  to  the  post-mortem  room  at  the 
Manchester  Eoyal  Infirmary,  found  as- 
cites in  56  per  cent. 

With  reference  to  these  figures,  it  must 
be  remembered  that  these  are  statistics, 
not  of  cases  of  portal  cirrhosis  recognized 
as  portal  cirrhosis  during  life,  but  in  the 
post-mortem  room,  and  this  will  explain 
the  low  percentage  here  given.  Never- 
theless they  show  very  clearly  that  ascites 
is  not  the  frequent  and  necessary  accom- 
paniment that  is  generally  held.  The 
fluid  in  these  cases  is  clear,  but  may  be 
slightly  bile-stained;  after  repeated  tap- 
ping it  assumes  more  the  character  of 
an  inflammatory  exudate.  According  to 
some  French  observers,  it  begins  as  a 
subacute  peritonitis;  this  is,  however, 
doubtful.  The  fluid  is  alkaline,  with  a 
specific  gravity  varying  between  1010 
and  1015,  though,  if  there  has  been  any 
peritonitis,  this  specific  gravity  and  the 
percentage  of  proteid  are  increased  and 
the  fluid  may  show  spontaneous  coagula- 
tion. Hale  White,  in  his  article  on  "Peri- 
hepatitis" (Allbutt's  "System  of  Medi- 
cine"), holds  that  ascites  proper  is  a  late 
event  in  cirrhosis,  for  which  more  than 
one  tapping  is  rarely  required,  and  re- 
gards those  cases  in  which  multiple  tap- 


pings are  necessary  as  being  complicated 
with  peritonitis;  indeed,  he  goes  so  far 
as  to  hold  that,  where  ascites  is  directly 
due  to  cirrhosis  and  paracentesis  is  ne- 
cessitated, the  patient  rarely  lives  long 
enough  after  the  first  tapping  for  the 
second  to  be  necessary.  Of  10  cases 
which  were  recorded  during  life  as  hav- 
ing cirrhosis,  but  were  tapped  oftener 
than  once,  of  4  at  post-mortem  examina- 
tion, 3  were  found  to  be  cases  of  chronic 
peritonitis  and  perihepatitis  and  1  of 
colloid  disease  of  the  peritoneum;  the 
remaining  6  had  more  or  less  chronic 
peritonitis  associated  with  the  cirrhosis 
which  was  present.  In  fact,  he  would 
employ  this  as  of  diagnostic  value  as  be- 
tween uncomplicated  cirrhosis  and  peri- 
tonitis or  perihepatitis  with  or  without 
cirrhosis. 

Form  of  cirrhosis  of  the  liver  conse- 
quent upon  the  circulatory  obstruction 
due  to  pericardial  lesions.  There  is,  at 
times,  a  clinical  dilEculty  as  to  whether 
an  hepatic  enlargement  with  more  or  less 
ascites  is  a  primary  or  secondary  disease, 
especially  where  there  are  obvious  phys- 
ical signs  of  a  valvular  lesion  and  hardly 
any  of  back-pressure.  Three  cases  of  this 
form  of  pseudocirrhosis  witnessed.  Pick 
(Zeit.  f.  klin.  Med.,  B.  29,  H.  5,  0,  '90). 

CEdema  of  the  feet  is  not  infrequently 
secondary  to  ascites,  and  is,  in  the  main, 
due  to  a  pressure  of  the  distended  ab- 
dominal contents  upon  the  veins  coming 
from  the  lower  extremities.  According 
to  Osier,  oedema  of  the  feet  may  precede 
the  development  of  the  ascites,  in  which 
case  it  is  to  be  ascribed  to  the  malnutri- 
tion of  the  patient  and  the  impoverished 
condition  of  the  blood.  The  dropsy 
rarely  becomes  general. 

Enlargement  of  the  Spleen. — This  is  far 
more  frequent  than  is  ascites.  Thier- 
felder  found,  out  of  172  cases,  only  39, 
or  22  to  23  per  cent.,  in  which  this  symp- 
tom was  absent;   indeed,  it  may  be  re- 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    SYMPTOMS. 


219 


garded  as  the  most  common  of  the  symp- 
toms associated  with  portal  cirrhosis. 
Oestreieh  is  inclined  to  believe  that  this 
enlargement  of  the  spleen  is  not  entirely 
due  to  portal  obstruction,  in  that  it  ap- 
pears at  so  early  a  stage  of  the  condition 
before  other  marked  signs  of  such  ob- 
struction are  evident;  indeed,  it  is  sug- 
gested that  the  toxic  causes  which  are  at 
work  to  produce  the  hepatic  lesion  bring 
about  enlargement  of  the  spleen. 

If  passive  congestion  be  the  cause  of 
splenic  enlargement,  why  is  the  spleen 
so  frequently  small  and  hard  in  eases 
of  chronic  passive  congestion  of  the  ab- 
dominal viscera  due  to  heart  disease? 
F.  P.  Weber  (Edin.  Med.  Jour.,  N.  S., 
vol.  ii,  p.  579,  '97). 

The  average  weight  in  the  spleen  in 
hepatic  cirrhosis  is  12.93  ounces,  while 
in  cardiac  eases  it  averages  only  7.32 
ounces.  Again,  the  greatest  enlargement 
of  the  spleen  is  not  found  where  the 
portal  obstruction  is  greatest,  but  in 
those  cases  of  portal  cirrhosis  where  as- 
cites is  delayed  till  the  last  or  is  wholly 
absent.  Kelynack  {Edin.  Med.  Jour., 
N.  S.,  vol.  ii,  p.  579,  '97). 

Weber,  like  Oestreieh,  is  of  the  opinion 
that  toxsemia  is  the  cause  of  the  enlarge- 
ment.   The  organ  is  enlarged  from  one- 
half  to  three  times  its  normal  size;  .in 
one  case  of  portal  cirrhosis  which  re- 
cently came  under  my  notice,  it  weighed 
720  grammes.    Describing  a  similar  case 
of  large  splenic  tumor,  Banti  compares 
it  with  the  malarial  spleen,  and  urges  the 
probable  infectious  origin  of  such  cases. 
Case  of  hypertrophic  cirrhosis  of  the 
liver  in  a  boy  9  years  old.     At  the  au- 
topsy the  liver  was  found  to  weigh  650 
grammes,    had    a    yellowish-green    color 
and  an  irregular  surface;   a  large  num- 
ber of  fibrous  bands  traversed   the   or- 
gan,   the    bile-ducts    were    dilated,    the 
spleen   hard.     Dellemagne  and   Tordens 
(Jour,  de  Clin,  et  de  ThOrnp.  Inf.,  vol. 
v.  No.  17,  '97). 

Ilwmorrlioids.  —  While     hcemorrhoids 
are  frequent  in  cases  of  portal  cirrhosis. 


the  majority  of  recent  writers  are  of  the 
opinion  that  they  are  far  from  being  as 
common  as  used  to  be  taught. 

Pain  and  Tenderness  over  the  Region  of 
the  Liver. — This  latter  is  often  most  no- 
ticeable in  the  early  stages,  and  is  often 
accompanied  by  a  sense  of  epigastric  full- 
ness and  tension,  which  may  be  present 
through  the  duration  of  the  disease.  As 
Ross  pointed  out  and  explained  in  his  re- 
markable article  in  the  tenth  volume  of 
Brain,  besides  these  sensations  referred 
directly  to  the  diseased  organ  (or  con- 
ditions of  splanchnic  pain),  there  may 
be  other  painful  sensations  which  may  be 
termed  somatic,  or  referred  pains.  The 
liver  is  innervated  from  the  seventh  to 
the  tenth  dorsal,  and,  as  a  consequence, 
the  pain  affecting  the  organ  may  be  re- 
ferred to  the  cutaneous  branches  of  these 
nerves  by  overflow  of  irritation  in  the 
cord,  and,  as  a  matter  of  fact,  pain  is 
frequently  felt  in  the  region  of  the  angle 
of  the  right  scapula.  Another  pain  at 
times  experienced  is  that  at  the  tip  of  the 
right  shoulder,  more  rarely  of  both 
shoulders.  Wliere  this  is  the  case  there 
is  an  indication  of  involvement  of  the 
upper  surface  of  the  organ,  extending  to 
the  diaphragm,  for  such  pain  is  brought 
about  by  the  overflow  of  irritation  at  the 
point  of  entry  of  the  phrenic  nerve  into 
the  spinal  cord;  and  so  there  is  reference 
to  pain  along  the  branches  of  the  lower 
cervical  nerves,  the  phrenic  arising  chiefly 
from  the  fourth  cervical  with  a  few  fila- 
ments from  the  third. 

Symptoms  Referable  to  Disturbed 
Function. — Jaundice. — One  of  the  most 
constant  symptoms  of  portal  cirrhosis  is  a 
slight  icteroid  tinge  of  the  conjunctivae 
accompanied  by  a  bright,  watery  appear- 
ance of  the  eyes.  The  skin,  in  general, 
save  where  there  is  frank  development  of 
ascites,  is  pale  rather  than  icteroid,  but  as 


220 


CIKKHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.     SYMPTOr^IS. 


the  disease  progresses  the  face  gains  a 
sallow,  ashy  tinge.  In  the  very  rare  ex- 
treme cases  of  pigmentary  cirrhosis  the 
skin  may  assume  a  slaty-bine  or  in  some 
cases,  as  in  diabetic  cirrhosis,  a  bronzed 
appearance  similar  to  that  seen  in  Addi- 
son's disease. 

Jaundice,  however,  may  show  itself  La 
any  period  of  the  disease;  it  is  charac- 
terized by  not  presenting  that  continuous 
and  progressive  severity  observable  in 
cases  of  true  biliary  cirrhosis.  Accord- 
ing to  Fagge,  at  Guy's  Hospital,  out  of 
130  cases,  only  35  showed  this  symptom, 
or  just  iinder  27  per  cent.,  and,  according 
to  Price  (quoted  by  Graham),  the  propor- 
tion is  lower,  namely:  17.5  per  cent. 

Urine. — In  the  earlier  stages  there  may 
■  be  little  or  no  change,  but,  as  the  condi- 
tion progresses,  the  quantity  diminishes 
in  amount,  the  color  becomes  dark,  and, 
as  Hayem  and  von  Jaksch  have  pointed 
out,  the  greatly-increased  amount  of 
urobilin  is  an  indication  of  considerable 
value  where  the  diagnosis  is  doubtful. 
Save  where  there  is  a  frank  condition  of 
jaundice,  bile-pigments  are  absent.  The 
urea  is  often  found  diminished;  the 
urates,  on  the  other  hand,  markedly  in- 
creased. Albumin  is,  at  times,  present, 
with  casts,  apart  from  those  casts  which 
may  be  associated  with  jaundice.  Kely- 
nack  found  renal  cirrhosis  present  in  a 
little  over  18  Va  per  cent,  of  his  cases. 

Study  of  the  urine  in  cirrhosis  of  the 
liver;  conclusions:  1.  The  quantity  of 
urea  eliminated  in  twenty-four  hours  is 
much  diminished,  but  presents  variations 
from  day  to  day.  2.  Milk  diet  augments 
the  elimination  of  urea  and  favors  diure- 
sis. 3.  With  the  diminution  of  the  elimi- 
nation of  urea,  that  of  ammonia  in- 
creases; with  a  milk  diet  this  ia  re- 
versed. 4.  The  chlorides  keep  pace  with 
the  urea.  5.  0.\idized  urocliionie  and 
urobilin  are  diminished  during  a  milk 
regimen.  Ajello  and  Solaro  (II  Mor- 
gagni,  Feb.,  '93). 


Case  of  a  patient  in  whom  cirrhosis  of 
the  liver  was  combined  with  diabetes 
mellitus.  He  was  under  observation  for 
nearly  eight  and  a  half  years.  The  first 
symptom  to  appear  was  slight  jaundice, 
followed  some  months  afterward  by  cer- 
tain diabetic  symptoms,  namely:  thirst, 
and  sugar  in  the  urine,  to  the  amount  of 
P/i  to  2  per  cent.  This  yielded  to  appro- 
priate treatment,  but  five  years  after- 
ward ascites  appeared,  along  with  slight 
jaundice,  enlargement  of  the  liver  and 
spleen,  and  some  dropsy  of  the  feet,  etc. 
At  the  necropsy,  marked  cirrhosis  of 
the  liver,  with  enlargement  of  the  spleen 
and  kidneys,  as  well  as  tubercular  de- 
posits (both  old  and  recent),  were  found. 
Hepatic  cirrhosis  in  such  eases  is  of  a 
special  kind  and  holds  an  intermediate 
position ;  it  is  characterized  by  marked 
increase  in  the  size  of  the  liver  and 
spleen,  with  but  little  tendency  to  con- 
traction on  the  part  of  the  former,  and 
also  by  the  presence  of  pigmentation  in 
the  skin.  Pusinelli  (Berl.  klin.  Woch., 
No.  33,  '90). 

The  presence  of  a  strong  perchloride 
of  iron  reaction  in  the  urine  of  several 
patients  sufTering  from  hepatic  cirrhosis 
noted.  The  color  obtained  was  some- 
times similar  to  that  seen  in  the  pres- 
ence of  diacetic  acid  in  diabetes  mel- 
litus, and  sometimes  to  that  obtained 
when  salicylic  acid  has  been  taken.  The 
appearance  of  the  reaction  sometimes 
coincided  with  very  threatening  general 
symptoms.  AVcbcr  (Brit.  Mod.  Jour., 
Jan.  2,  1904). 

The  Blood. — There  is  very  little  that  is 
characteristic  about  the  condition  of  the 
blood  in  portal  cirrhosis.  There  is  no 
marked  increase  in  leucocytes,  no  ex- 
tensive diminution  cither  of  the  hnemo- 
globin  or  of  the  number  of  red  blood- 
corpuscles,  but  the  tendency  toward  epis- 
taxis  and  the  development  of  petechiiE 
in  connection  with  the  general,  as  op- 
posed to  the  portal,  circulation  would 
seem  to  indicate  that  either  the  blood  is 
of  such  a  poor  quality  or  contains  such 
abnormal  and  toxic  substances  as  to  lead 
to  degeneration  of  the  capillary  walls, 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    DIAGNOSIS. 


221 


and,  as  already  pointed  out,  the  occa- 
sional occurrence  of  oedema  preceding 
ascites  is  another  indication  of  this  toxic 
or  impoverished  condition  of  this  fluid. 
While  the  hospital  is  of  such  relatively- 
recent  estahlishment,  and  the  number  of 
cases  of  portal  cirrhosis  in  post-mortem 
records  too  few  to  establish  definite  state- 
ment, I  have  been  struck  by  the  fre- 
quency with  which,  during  life,  the  clin- 
ical records  at  the  Royal  Victoria  Hos- 
pital, Montreal,  note  an  apical  systolic 
murmur,  recognized  as  functional,  the 
post-mortem  confirming  its  functional 
nature. 

A  further  indication  of  the  altered  or 
thinned  condition  of  the  blood  is  the 
not-infrequent  existence  of  a  venous  hum 
in  the  epigastric  region  noted  by  several 
recent  observers  and  of  a  splenic  souffle 
first  noted  by  Bouchard. 

Other  Symptoms  Beferahle  to  Disturbed 
Hepatic  Function. — Very  characteristic 
toward  the  latter  stage  are  certain  nerv- 
ous symptoms,  which  also  are,  in  general, 
attributed  to  a  toxic  condition  of  the 
blood.  These  are,  by  some,  classed  as 
manifestations  of  cholsemia,  although,  as 
they  may  be  present  when  there  is  no  evi- 
dence of  the  passage  of  bile  into  the 
blood,  this  use  of  the  term  is  scarcely  ex- 
act. I  refer  to  the  drowsiness  of  many 
patients  and  the  more  marked  nervous 
conditions  of  coma  and  delirium.  Wliere 
death  is  not  due  to  htemorrhage  or  inter- 
current disease,  such  as  tuberculosis,  it  is 
these  nervous  disturbances  which  are  the 
pronnnent  feature  in  the  fatal  event. 
Those  nervous  symptoms  may  be  mis- 
taken for  the  onset  of  urrcmia.  There 
may  be  marked  excitation,  or,  on  the 
other  hand,  a  progressive  and  deepening 
stupor  passing  into  complete  coma. 

Case  of  lifBiiioirhage  from  the  larynx 

in    the    course    of    alcoholic    cirrhosis. 

Hteniatemesis  and  cpistaxis  also  occurred. 

Laryngeal  htemorrhage  ascribed  to  the 


interference  with  the  biEmatopoietic 
functions  of  the  liver  by  the  atrophic 
cirrhosis  of  that  organ.  Lubet  Barbou 
(Archives  de  Laryn.,  July,  Aug.,  '97). 

Study  of  8i.\ty  cases  of  fatal  gastro- 
intestinal hfcmorrhage  due  to  cirrhosis 
of  the  liver.  1.  Fatal  gastro-intcstinal 
haemorrhage  is  an  infrequent,  but  not 
rare,  complication  of  cirrhosis  of  the 
liver.  2.  In  the  great  majority  of  the 
eases  the  cirrhosis  is  atrophic,  but  it  may 
be  hypertrophic.  3.  In  one-third  of  the 
cases  the  first  hremorrhage  is  fatal;  in 
the  other  two-thirds  the  haemorrhages 
continue  at  interi'als  over  a  period  vary- 
ing from  a  few  months  to  several  years, 
the  maximum  given  being  11  years.  4. 
In  one-third  of  the  cases  the  diagnosis 
can  be  made  at  or  before  the  time  of  the 
first  htemorrhage.  In  the  other  cases  the 
diagnosis  cannot  be  made  at  all  or  only 
after  months  or  years,  during  which  time 
other  symptoms  of  cirrhosis  may  have 
developed.  5.  ffisophageal  varices  are 
present  in  80  per  cent,  of  the  cases,  and 
in  more  than  half  of  this  80  per  cent, 
the  varices  show  macroscopical  ruptures, 
and  it  is  probable  many  other  ruptures 
would  be  found  if  the  varices  were  tested 
by  injections  of  air  or  fluid.  6.  Fatal 
haemorrhages  occur  in  cases  which  show 
no  oesophageal  varices,  and  they  are  prob- 
ably due  to  the  simultaneous  rupture  of 
many  capillaries  of  the  gastrointestinal 
mucous  membrane.  7.  The  haemorrhages 
in  this  class  of  cases  are  usually  preceded 
by  other  symptoms  of  cirrhosis,  but  the 
first  symptom  may  be  a  fatal  htemor- 
rhage. 8.  In  G  per  cent,  only  of  the  cases 
which  showed  cesophageal  varices  was 
the  cirrhosis  typical:  i.e.,  showed  ascites, 
enlarged  spleen,  and  subcutaneous  ab- 
dominal varices.  R.  B.  Preble  (Amer. 
Jour.  Med.  Sei.,  Mar.,  1900). 

Differential  Diagnosis. — The  preced- 
ing pages  will  have  given  in  fairly  full 
detail  the  main  features  characterizing 
the  different  forms  of  hepatic  cirrhosis. 
Here,  however,  it  may  be  worth  while  to 
point  out  again  that  there  are  four  forms 
of  hepatic  cirrhosis,  or  of  conditions  clin- 
ically regarded  as  cirrhosis,  between 
which  we  have  to  distinguish,  namely: 


222 


CIRRHOSIS  OF  THE  LIVEK.    PORTAL  CIKRHOSIS.    DIAGNOSIS. 


portal  cirrhosis  proper,  biliary  cirrhosis, 
chronic  perihepatitis,  and  gummatous 
syphilis  of  the  liver.  All  other  forms, 
with  the  exception  of  the  pericellular 
syphilitic  cirrhosis  of  the  infant,  are 
clinically  unrecognizable. 

Leaving  aside,  for  the  moment,  the 
most  important  of  these, — namely,  portal 
cirrhosis, — the  main  features  whereby 
the  biliary  form  of  the  disease  is  to  be 
differentiated  are  the  progressive  icterus, 
the  enlargement  of  the  organ,  the  ab- 
sence of  marked  digestive  disturbances, 
the  long  continuance  of  the  condition, 
and  the  retention  of  appetite  and 
strength.  The  coloration  of  the  stools 
by  bile  and  the  more  extensive  enlarge- 
ment of  the  organ  must  be  the  main 
factors  in  diagnosing  between  what  we 
may  term  the  catarrhal  form  of  biliary 
cirrhosis  and  the  very  rare  purely-ob- 
structive form. 

Gummatous  syphilis  is  only  likely  to 
be  confounded  with  portal  cirrhosis 
when,  through  obstruction  to  the  portal 
circulation,  ascites  supervenes.  Under 
these  conditions  the  organ  may  be  either 
of  normal  size  or  greatly  contracted  by 
a  multitude  of  syphilitic  cicatrices.  In 
the  former  case  the  coarse  lobulation  of 
the  organ  is  more  likely  to  lead  to  the 
diagnosis  of  cancer  of  the  organ  than  of 
portal  cirrhosis;  in  the  latter  case  the 
signs  and  symptoms  may  be  so  closely 
allied  to  those  of  portal  cirrhosis  as  to 
render  diagnosis  a  matter  of  extreme  dif- 
ficulty. The  presence  of  syphilitic  lesions 
elsewhere,  and  the  history  of  the  case, 
may  help  toward  the  diagnosis,  which 
will  be  finally  determined  by  the  effects 
of  antisyphilitic  treatment. 

0ENi;nAIJ7,KD  FIBROID  PERinEPATITIS 

may,  with  great  difficulty,  be  distinguish- 
able from  true  portal  cirrhosis.  If  the 
organ  can  be  felt,  the  rounded  character 
of  the  edge,  the  absence  of  roughness  of 


fine  nodulation  on  palpation,  the  pres- 
ence of  a  thickened  omental  mass  below 
the  liver,  all  are  in  favor  of  a  diagnosis 
of  perihepatitis.  As  already  stated,  ac- 
cording to  Hale  White,  if  a  patient  is 
able  to  stand  a  long  series  of  tappings  of 
the  ascitic  fluid,  the  diagnosis  is  against 
the  existence  of  an  uncomplicated  portal 
cirrhosis,  and  is  in  favor  either  of  chronic 
peritonitis  associated  with  perihepatitis 
or  of  portal  cirrhosis  complicated  by 
chronic  peritonitis. 

The  main  points  elicited  in  the  pre- 
ceding pages  with  regard  to  portal  cir- 
rhosis and  its  diagnosis  are  the  follow- 
ing:— 

1.  That  the  small  size  of  the  organ  is 
by  no  means  the  main  diagnostic  feature 
of  this  condition.  Only  in  advanced 
cases,  and  by  no  means  always  then,  is 
the  organ  markedly  atrophied.  Of  far 
greater  diagnostic  importance  is  the  de- 
termination of  progressive  diminution 
in  size  of  the  organ. 

2.  If  the  organ  be  palpable,  the  recog- 
nition of  a  finely-nodular,  firm  surface 
indicates  with  relative  certainty  the  ex- 
istence of  this  condition. 

3.  Contrary  to  general  opinion,  in  only 
about  50  per  cent,  of  the  cases  in  which 
the  autopsy  reveals  a  well-developed  con- 
dition of  portal  cirrhosis  is  there  ascites. 

4.  Enlargement  of  the  spleen  is  a 
much  commoner  symptom,  and  this  is 
present  in  more  than  80  per  cent,  of  the 
cases. 

5.  Jaundice  is  present  in  about  30  per 
cent,  of  cases.  Such  jaundice  tends  to 
be  transient  and  to  develop  after  other 
symptoms  have  been  present  some  little 
time. 

6.  From  the  very  onset  of  the  condi- 
tion gastric  and  intestinal  disturbances 
form  a  prominent  feature  in  the  disease. 

7.  The  progressive  emaciation  and 
weakness  are  also  characteristic,  and  with 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    DLA.GNOSIS. 


223 


this  may  be  associated  a  peculiar,  sallow, 
slightly-earthy  complexion. 

8.  A  urine  free  from  sediment  (mainly 
of  urates)  is  against  the  diagnosis  of  cir- 
rhosis; -while  the  presence  of  increased 
quantities  of  urobilin  is,  in  the  presence 
of  other  symptoms,  in  favor  of  such  a 
diagnosis. 

Of  other  conditions  affecting  the  liver 
which  may  be  confounded  with  cirrhosis 
are  to  be  mentioned  cancer,  thrombosis 
of  the  portal  vein,  senile  or  marantic 
atrophy  of  the  liver,  and  cyanotic  indura- 
tion. 

Of  these,  portal  thrombosis  may  oc- 
cur as  a  complication  of  cirrhosis.  Where 
this  occurs  in  the  absence  of  cirrhosis  the 
main  distinguishing  feature  is  the  rapid 
development  of  the  ascites  and  its  rapid 
return  after  tapping.  At  the  same  time, 
such  thrombosis  is  secondary  to  disease 
of  other  abdominal  organs,  more  fre- 
quently of  the  intestinal  tract,  and  the 
symptoms  proper  to  such  disease  will 
have  preceded  the  development  of  ascites. 

Cancer  of  the  liter  is  characterized 
by  the  increase  in  size  of  the  organ,  the 
presence  of  large  nodules  presenting  um- 
bilication,  the  absence  of  splenic  enlarge- 
ment, the  cancerous  fades,  and,  in  gen- 
eral, the  presence  of  cancerous  nodules 
elsewhere.  Those  cases  in  which  cancer 
of  the  organ  is  present  without  the  de- 
velopment of  nodules  upon  the  anterior 
surface  of  either  lobe  at  times  cause  very 
great  difficulty.  Here  the  small  size  of 
the  spleen,  the  character  of  the  urine, 
the  complexion,  and  other  signs  and 
symptoms,  which  ordinarily  are  regarded 
as  of  secondary  importance,  become  of 
the  highest  value  in  diagnosis. 

Attention  called  to  the  occasional  re- 
semblance between  hypertrophic  cirrhosis 
and  hepatic  carcinoma,  and  stress  laid 
upon  the  di (Terence  in  the  stools,  which 
are  bilious  in  the  former,  clay-colored  in 


the    latter.     Freyhan    (Deutsche    med.- 
Zeit.,  May  8,  '93). 

In  cases  of  senile,  or  marantic, 
atrophy  the  organ,  if  it  can  be  pal- 
pated, is  smooth;  there  is  absence  of 
ascites  and  of  jaundice. 

The  atrophic  nutmeg  liver  (cya- 
notic induration)  and  also  the  "hyper- 
trophied"  nutmeg  liver  are  also  charac- 
terized by  the  smooth  surface  of  the 
organ,  as  also  by  the  prominent  symp- 
toms of  obstructive  disease  of  the  heart. 

Other  forms  of  ascites  and  peritonitis 
are  not  infrequently  mistaken  for  the 
results  of  cirrhosis;  indeed,  I  think  it 
may  be  said  with  confidence  that  the 
most  frequent  cause  of  false  diagnosis  of 
cirrhosis,  is  either  cancerous  or  tuber- 
cular peritonitis.  In  such  cases  there 
may  be  present  gastric  and  intestinal 
disturbances  easily  mistaken  for  those 
accompanying  cirrhosis;  the  ascites  may 
be  of  gradual  development,  as  in  portal 
cirrhosis;  and  the  liver,  being,  by  the 
accumulation  of  fluid,  forced  upward, 
may  disappear  behind  the  ribs  and  so  be 
diagnosed  as  presenting  great  atrophy. 
Between  cancerous  and  tubercular  peri- 
tonitis the  distinction  may  be  drawn  that 
in  the  former  the  spleen  is  not  enlarged, 
and  in  the  latter  the  enlargement  may 
be  as  extensive  as  in  portal  cirrhosis.  In 
these  cases,  again,  it  is  the  secondary 
symptoms  and  signs  which  are  of  the 
greatest  value  in  arriving  at  a  decision: 
complexion,  urine,  etc.,  and,  in  addition 
to  these,  the  character  of  the  abdominal 
fluid  when  removed.  Most  important, 
also  are  manifestations  of  disease  else- 
where, either  cancerous  or  tubercular.  In 
cases  of  doubt,  to  determine  the  tuber- 
culous nature  of  the  condition,  it  is  well 
to  inoculate  a  rabbit  or  guinea-pig,  and, 
for  the  recognition  of  cancer,  to  make  a 
careful  search  for  cancer-cells  in  the  re- 
moved fluid. 


224 


CmRHOSIS  OF  THE  LIVEK.    POETAL  CIRRHOSIS.    COMPLICATIONS. 


Complications. — Leaving  out  of  ac- 
count the  rare  cases  of  development  of 
a  priman'  adenomatous  or  cancerous  con- 
dition, there  may  be  other  complicating 
conditions  in  the  liver  itself  of  the  nature 
of  degenerative  changes;  in  advanced 
cases  it  is  not  infrequent  to  meet  with 
evidence  of  fatty  degeneration  of  the 
ceUs  as  distinct  from  the  fatty  infiltra- 
tion seen  in  less  advanced  conditions; 
more  rarely  is  amyloid  degeneration 
present.  Thrombosis  of  the  portal  vein 
occurs  occasionally. 

Tuberculosis. — The  most  frequent 
complication  outside  the  liver  is  the  de- 
velopment of  tuberculosis.  Eolleston 
and  Fenton  find  pulmonary  tuberculosis 
in  32  out  of  114  cases,  tuberculosis  being 
the  direct  cause  of  death  in  17.  Kely- 
nack,  out  of  121  cases,  finds  tuberculosis 
either  active,  latent,  or  obsolete  in  28: 
i.e.,  23  per  cent.  Of  these  28,  in  14  the 
condition  was  active  in  the  lungs,  in  12 
in  the  peritoneum,  and  in  7  both  in  the 
lungs  and  peritoneum.  Twelve,  or  about 
10  per  cent.,  of  the  cases  died  directly 
from  tuberculosis;  in  8  per  cent,  the 
condition  was  latent  or  obsolete. 

Tuberculosis  is  a  cause  of  cirrhosis  of 
the  liver.  The  liver  becomes  generally 
atrophied,  indurated,  and  granular,  like 
the  cirrhosis  which  results  from  the  abuse 
of  alcohol,  although  in  a  less  degree. 
More  rarely,  it  becomes  deeply  furrowed 
and  lobulated,  as  in  syphilitic  ciiThosis. 
Hanot  and  Gilbert  (La  Sem.  Med.,  Feb. 
3,  '92). 

Other  frequent  complications  are: 
EiGHT-siDKD  PLEURISY  with  a  serous  or 
sero-sanguineous  exudation.  This  con- 
dition has  not,  as  yet,  been  thoroughly 
worked  out;  bo  far  as  I  can  see  it  is  not 
of  a  tuberculous  nature,  for  I  have  come 
across  cases  showing  such  pleurisy  in 
which  there  has  not  been  a  sign  of  tuber- 
culosis at  the  post-mortem.  Where  it  is 
present  I  have  also  noted  a  co-existence 


of  adhesions  between  the  upper  surface 
of  the  liver  and  the  diaphragm,  which 
might  indicate  an  extension  of  the  in- 
flammatory process  from  the  liver  to  the 
pleural  cavity.  Were  this  so,  it  would 
be  evidence  in  favor  of  microbic  origin  or 
microbic  complication  in  the  hepatic  con- 
dition; but,  as  already  stated,  this  sub- 
ject requires  much  further  study;  oc- 
casionallj'  there  is  evidence  of  bilateral 
pleurisy. 

Pleuritic    efi'usion    on    the    right    side 
only,  in  Laennec's,  generally  considered 
as  an  exceptional  symptom  is,  however, 
a   constant    symptom.     Found   in   nine 
cases  of  cirrhosis.    It  is  of  value  in  the 
diagnosis  of  doubtful  cases,  when  it  is 
difficult  to  determine  whether  ascites  is 
due  to  cirrhosis  of  the  liver,  to  throm- 
bosis of  the  portal  vein,  or  to  compres- 
sion of  that  vessel  by  tumors  or  swelled 
glands.      G.    Villani    (Riforma    Medioa, 
Mar.  9,  '95). 
Another  frequent  complication  is  ne- 
phritis, either  of  the  granular  type  or 
not  infrequently  as  a  mixed  interstitial 
nephritis,  of  what  Formad  has  termed 
the  'Tiog-backed"  type,  the  organ  being 
enlarged,   more   especially  from  before 
backward,  and  showing  microscopically 
a   condition   of   mixed   interstitial   and 
parenchymatous  nephritis.     The  inter- 
stitial type  is,  in  general,  associated  with 
evidences  of  some  degree  of  general  ar- 
teriosclerosis and  with  other  complica- 
tions due  to  this  process.    Both  the  inter- 
stitial and  the  hog-backed  kidney  are,  it 
need  scarcely  be  said,  characteristic  of 
alcoholism.    The  statistics  of  the  various 
authorities  with  regard  to  the  frequency 
of  renal  complications  are  not  sulficiently 
extensive  to  arrive  at  any  very  satisfac- 
tory conclusion.    G.  Foerster,  in  his  31 
cases  recorded  at  Berlin,  found  nephritis 
3  times,  granular  atrophy  4  times,  and 
"indurated"  kidney  4  times.     Kelynack 
found  renal  cirrhosis  in  a  little  over  18  Vj 
per  cent,  of  his  cases.    Giirtner  found  11 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    TREATMENT. 


225 


out  of  12  to  show  "chronic  nephritis"; 
10  of  these  were  habitual  drinkers  of 
brandy. 

Other  alcoholic  complications  may  also 
be  present,  notably  some  extent  of 
chronic  pachymeningitis  and  thickening 
of  the  dura  mater,  and  fatty  degeneration 
of  the  heart-muscle. 

Lastly  there  is  a  liability  for  acute  in- 
flammatory processes  to  supervene:  pneu- 
monia, acute  bronchitis  and  pericarditis, 
erysipelas  of  the  cedematous  skin,  and 
acute  peritonitis;  this  last  often  second- 
ary to  paracentesis. 

There  are  two  forms  of  recognized 
"appendicular  liver,"  a  purulent,  infec- 
tious hepatitis,  and  a  toxic  hepatitis, 
characterized  by  degeneration  of  the 
parenchyma,  neither  of  which  is  at  all 
rare.  Cirrhosis  is  another  sequel  which 
deserves  careful  study.  In  a  boy,  aged 
IG  years,  who  died  of  acute  appendicitis, 
the  necropsy  disclosed  all  organs  save 
the  appendix  and  liver  to  be  in  a 
healthy  condition.  The  liver  showed  an 
early,  but  unmistakable,  cin'hotic  proc- 
ess. The  personal  history  of  the  body 
had  been  excellent.  Tuffier  and  MautC 
(Tresse  MCd.,  June  20,  1004). 

Prognosis. — The  condition  begins  so 
insidiously  that  it  is  difficult  to  make  an 
accurate  statement  concerning  its  dura- 
tion. It  will  be  generally  agreed  that 
Fitz  is  not  too  hopeful  in  stating  that 
the  fatal  result  may  be  expected  within 
a  year  after  hcemorrhage  or  other  sign  of 
portal  obstruction.  Von  Kahlden  in- 
stances a  case  (Miinch.  med.  "Woch.,  4S, 
'97)  of  a  very  acute  development  of  the 
disease  in  which  death  occurred  three 
and  a  half  months  after  the  first  symp- 
toms presented  themselves.  The  form  of 
cirrhosis  in  this  was  of  a  mixed  tj'pe.  If 
the  cases  of  Carrington  and  Caylcy  are 
to  be  regarded  also  as  examples  of  portal 
cirrhosis,  we  have  further  evidence  that 
the  disease  may  be  fatal  in  three  months 
after  the  first  occurrence  of  dyspepsia 


and  of  epigastric  fullness,  or  two  months 
after  the  first  onset  of  ascites.  At  the 
other  extreme,  we  come  across  many 
cases,  in  the  post-mortem  room,  of  well- 
developed  portal  cirrhosis  which  had 
given  rise  to  no  symptoms  during  life. 
Thus,  clearly  the  condition  may  be  pres- 
ent in  a  latent  or  it  may  be  in  an  arrested 
form  for  months  and  it  may  be  for  years. 
It  is  difficult  to  explain  otherwise  a  case 
such  as  that  of  Taggert's,  in  which  the 
cirrhotic  tissue  had  undergone  calcifica- 
tion. It  is  difficult,  also,  to  know  how  to 
regard  those  cases  in  which,  cirrhosis 
being  diagnosed,  after  one  or  two  tap- 
pings the  symptoms  disappear  and  the 
patients  apparently  recover,  because  these 
cases  may  have  been  conditions,  not  of 
true  cirrhosis,  but  of  subacute  perihepa- 
titis. If,  by  palpation  and  by  other  phys- 
ical signs  and  symptoms,  and  more  es- 
pecially by  the  character  of  the  urine,  it 
is  determined  that  portal  cirrhosis  is 
present,  prognosis  is  very  bad. 

Both  Eolleston  and  Kelynack  agree 
that  a  little  under  half  the  cases  die  di- 
rectly from  the  effects  of  hepatic  cir- 
rhosis, though  it  is  a  little  doubtful  what 
effects  they  include  under  this  term. 

Treatment. — There  is  no  treatment 
known  save  the  palliative,  and  it  is,  in- 
deed, difficult  to  see  how  to  arrest  the 
condition  once  there  is  marked  develop- 
ment of  this  contracting,  fibrous  tissue 
in  the  organ.  The  avoidance  of  alcohol, 
spices,  coffee,  and  other  irritant  sub- 
stances; avoidance  of  fatigue  and  of  cold, 
together  with  maintenance  of  regular 
action  of  the  bowels  by  mild  aperients 
are  all  indicated.  Several  authorities 
have  recommended  a  milk  diet,  but,  ac- 
cording to  Jaccoud  and  others,  it  has 
absolutely  no  effect  in  arresting  the 
progress  of  the  disease. 

In    cirrhosis    of    the    liver    abstention 
from  alcohol  and  all  stimulating  ingesta 


226 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    TREATMENT. 


is  the  first  requisite.  Diet  sliould  be  je- 
strictfd  to  milk,  eggs,  simple  proteids, 
bread,  and  fresh  fruit  and  vegetables. 
Predigested  foods  are  necessary  in  some 
instances.  W.  B.  Cheadle  (Lancet,  Apr. 
14,  1900). 

Some  more  recent  writers  recommend 
massage  as  improving  the  general  con- 
dition of  the  patient.  The  treatment 
which  affords  most  relief  would  appear 
to  be  the  employment  of  alkaline  mineral 
waters  and  saline  purgatives,  whereby 
some  relief  is  given  to  the  congestion  of 
the  portal  system. 

TMiere  ascites  is  present,  tapping  gives 
great  relief,  and,  as  pointed  out  by 
Murchison  and  recommended  by  Graham 
in  his  admirable  article  in  the  Loomis- 
Thompson  "System  of  Practical  Med- 
icine," after  this  tapping  digitalis  and 
diuretics  are  both  effectual  and  useful. 

Special  attention  drawn  to  the. value 
of  urea  as  a  diuretic.  Two  and  a  half 
drachms  given  in  the  day,  increased  up 
to  5  drachms,  continued  for  2  or  3 
weeks.  No  unfavorable  effects  witnessed. 
The  unpleasant  taste  may  be  done  away 
with  by  drinking  milk  immediately  after 
taking  it.  G.  Klemperer  (Berl.  klin. 
Woch.,  Jan.  6,  '90). 

The  treatment  should  be  largely  di- 
etetic and  hygienic,  great  care  being 
taken  to  see  that  the  functions  of  the 
gastro-intestinal  tract  are  kept  in  ac- 
tion and  the  renal  secretions  properly 
regulated  as  well  as  tlie  action  of  the 
skin.  Three  deaths  personally  known 
to  have  followed  the  operative  treat- 
ment of  hemorrhoids,  and  at  the  ne- 
cropsy cirrhosis  of  the  liver  was  dis- 
covered for  the  first  time.  In  all  cases 
of  hccmorrhoidal  disease  a  thorough 
knowledge  of  the  stale  of  the  liver 
sliould  be  obtained  liefore  any  operative 
interference  is  advised.  In  the  treat- 
ment of  ascites  mild  purgation  and  calo- 
mel from  time  to  time;  calomel  also 
UBcd  in  Vin-Rrain  dose  every  three  hours 
as  a  diuretic.  The  old-fashioned  pill, 
digitalis,  squills,  and  calomel  and  co- 
paiba are  useful.    Tapping  is  resorted  to 


early    and    frequently.      J.    H.    Musser 
(Phila.  Med.  Jour.,  June  15,  1901). 

After  liEemorrhage  from  the  oesoph- 
agus of  the  stomach,  ice  should  be 
taken  internally  and  morphine  may  be 
given. 

The  operation  of  bleeding  has  so  fallen 
into  disuse  that  scarce  any  authority 
recommends  this  as  a  means  of  rapidly 
relieving  the  congestion.  Personally  1 
have  been  struck  at  autopsies  by  the 
amount  of  blood  still  present  in  the 
organs  even  when  profuse  hasmorrhage 
has  been  the  cause  of  death;  and  it  seems 
worth  while  to  suggest  that,  where  other 
means  fail,  the  removal  of  blood  from  the 
general  circulation,  by  temporarily  low- 
ering the  general  blood-pressure,  is  ca- 
pable of  aiding  the  more  rapid  flow  of 
blood  from  the  congested  portal  circula- 
tion into  the  inferior  vena  cava  and  vena 
azygos,  and  so  is  capable  of  aiding  the 
development  of  a  more  satisfactory  col- 
lateral circulation. 

Surgical  Treatment  of  Abdominal 
Dropsy  Following  Cirrhosis  of  the 
Liver.  —  The  operation  devised  by 
Talma  consists  of  an  abdominal  section, 
preferably  between  the  umbilicus  and 
ensiform  cartilage,  evacuation  of  the  ac- 
cumulated fluid,  and  scraping  of  the 
parietal  peritoneum  with  a  curette  or 
rubbing  off  the  epithelium  with  a  gauze 
sponge.  The  superior  surfaces  of  the 
liver  and  of  the  peritoneum  covering  the 
diaphragm  are  also  rublied.  The  omen- 
tum for  three  or  four  inches  around  the 
incision  is  then  stitched  to  the  parietal 
wall,  and  is  included  in  the  sutures 
which  close  the  abdominal  incision.  A 
broad  surface  is  available  for  adhesions, 
and  it  is  the  additional  collateral  circu- 
lation thus  obtained  which  constitutes 
the  main  feature  of  the  operation.  Its 
formation,  however,  is  comparatively 
slow,  and  it  is  frequently  necessary  to  lap 


CIRRHOSIS  OF  THE  LIVER.    PORTAL  CIRRHOSIS.    TREATMENT. 


^27 


the  patients  several  times  after  the  oper- 
ation, before  the  collateral  circulation  is 
complete. 

Since  the  first  operation  for  cirrhosis 
of  the  liver,  13  have  been  performed. 
Of  these,  5  have  recovered,  2  were  im- 
proved, in  1  there  was  no  change,  and 
5  died.  Operation  is  indicated  in  cases 
in  which  there  is  a  distinct  mechanical 
hindrance  in  tlie  portal  circulation  with 
recurring  ascites.  The  technique  consists 
of  a  small  incision  into  the  abdominal 
cavity,  through  which  a  careful  explora- 
tion is  made  of  the  liver,  gall-bladder, 
and  the  surrounding  parts.  The  peri- 
toneum is  curetted  over  the  anterior  sur- 
face of  the  abdomen,  and  the  great  omen- 
tum is  attached  by  sutures  to  the  ab- 
dominal wall.  The  peritoneum  has  its 
epithelial  covering  removed  over  the 
lateral  and  anterior  portion  on  the  left 
side  of  the  abdomen,  to  which  the  spleen 
is  likewise  attached.  A  glass  drain  is 
then  inserted,  and  all  ascitic  fluid  of  the 
abdominal  cavity  is  removed.  This 
drainage  is  continued  until  no  further 
fluid  is  formed,  which  shows  that  the 
collateral  circulation  has  been  estab- 
lished. F.  Friedmann  (Centralb.  f.  d. 
Grenzgebiete  der  Med.  u.  Chir.,  Aug.  8, 
1900). 

The  operation  for  creating  compensa- 
tory circulation  in  hepatic  cirrhosis  is 
indicated  in  those  cases  in  which  the 
collateral  circulation  is  not  sufficiently 
established  to  relieve  the  rapidly  in- 
creasing ascites.  Although  the  cases 
operated  on  by  Talma  himself  proved 
fatal,  it  was  successful  in  6.5  per  cent, 
of  cases  operated  by  other  surgeons. 
Two  personal  cases  reported  in  which 
Talma's  operation  was  performed.  Two 
months  later  ascites  again  developed, 
six  litres  of  fluid  having  been  removed 
by  tapping.  After  that  the  patient  felt 
much  stronger.  The  second  case  pre- 
sented a  history  of  chronic  alcoholism, 
and  was  far  advanced  in  the  disease 
when  Talma's  operation  was  performed. 
He  improved  after  it  for  about  two 
weeks,  when  he  commenced  to  decline 
rapidly,  and  died  within  forty-eight 
hours.  It  is  a  simple  and  harmless 
inethod  of  treating  ascites.  N.  M.  Ben- 
isovitch  (Vratch,  Fob.  17,  1901). 


All  well-attested  cases  of  cirrhosis 
presenting  ascites  should  be  operated 
upon  under  local  anaesthesia.  Frazier's 
table  of  fifteen  cases  reproduced,  per- 
sonal case  being  the  fifteenth  in  the 
table.  Frazier's  list  shows  that  75  per 
cent,  of  recoveries  had  taken  place.  J. 
J.  Jelks  (Med.  Record,  Mar.  23,  1901). 

Case  of  hepatic  cirrhosis  in  which 
Talma's  operation  was  performed  about 
a  jear  ago.  The  liver  and  spleen  were 
In  the  same  condition;  the  circulation 
had  improved;  collateral  circulation 
was  well  established;  and  the  ascites 
did  not  recur.  Scherwincky  (Med.  Obos- 
renije,  Mar.,  1901). 

Statistics  show  that  six  cases  at  least 
have  been  cured  of  ascites  by  stitching 
the  omentum  to  the  anterior  abdominal 
wall,  and  which  remained  well  for  a 
period  of  two  years  or  more.  Six  others 
were  relieved  of  this  symptom  for  from 
two  to  six  months,  but  died,  either  with- 
out a  return  of  the  ascites  or  have  been 
under  observation  long  enough  to  dem- 
onstrate that  the  cure  is  permanent.  A 
ease  of  ha;raorrhage  from  the  alimentary 
canal  was  promptly  cured  by  the  above 
operation.  Thirty-eight  cases  recovered 
trom  the  operation,  and,  when  we  con- 
sider that  in  the  majority  of  instances 
these  patients  were  in  the  last  stages 
of  an  incurable  disease  and  would  have 
died  within  a  few  weeks,  it  seems  that 
if  these  cases  were  taken  earlier  there 
would  have  been  more  encouraging  re- 
sults. G.  E.  Brewer  (Medical  News, 
Feb.  8,  1902). 

Six  cases  in  which  Talma's  operation 
of  suturing  the  omentum  to  the  an- 
terior abdominal  wall  for  ascites  due 
to  ciiThosis  of  the  liver  was  resorted  to. 
The  omentum  was  sutured  to  the  ab- 
dominal wall  in  such  a  manner  that  a 
part  of  it  lay  between  the  skin  and 
the  parietal  peritoneum.  The  skin 
over  this  was  sutured  without  leaving 
any  space  for  drainage.  One  patient 
lived  five  months  after  the  operation, 
and  had  to  be  tapped  again  on  account 
of  the  rcaccumulation  of  fluid.  Another 
patient  lived  only  two  weeks  after  the 
operation;  a  third  lived  eleven  months 
after  the  operation.  A  fourth  patient 
improved    considerably    and    was    dis- 


228 


CIRRHOSIS  OF  THE  LIVER.    BILIARY  CIRRHOSIS.    VARIETIES. 


charged  from  the  hospital  apparently 
cured,  but  was  not  followed  afterward. 
The  other  two  patients  sunived  the 
operation,  but  left  the  hospital  too 
early  to  warrant  any  conclusion  as  to 
the  permanent  eflfects  of  the  procedure 
upon  their  ascites.  Ko?lovsky  (Rous- 
sky  Vratch,  Nov.  29,  1903). 

Biliary  Cirrhosis. 

Under  the  term  "13111317  cirrhosis"  two 
distinct  conditions  are  to  be  Included: — 

1.  A  condition  rare,  clinically,  but  pro- 
duced experimentally  In  the  lower  ani- 
mals by  Charcot  and  Gombault  by  lig- 
ature of  the  common  bile-duct.  A  condi- 
tion In  which  obstruction  of  the  larger 
bile-ducts  Is  followed  by  Inflammatory 
condition  of  the  intrahepatic  and  extra- 
hepatic  bile-ducts,  and  the  later  devel- 
opment of  fibrous  tissue  around  them. 

2.  A  condition  in  which  the  liver  is 
fotmd  permanently  enlarged,  with  the 
development  of  much  rather  loose  and 
non-contracting  fibrous  tissue,  in  which, 
as  evidenced  by  the  accompanying  jaun- 
dice, there  is  some  hindrance  to  the  free 
flow  of  bile  through  the  smaller  ducts, 
for  no  obstruction  of  the  extrahepatlc 
bile-ducts  Is  to  be  recognized. 

A  further  characteristic  of  this  form 
is  the  peculiar  extensive  development  of 
the  already-described  new  bile-ducts  in 
the  hyperplastic  fibrous  tissue. 

1.   Obstructive  Cirehosis. 

Definition. — The  cirrhosis  of  obstruc- 
tion of  the  large  bile-ducts. 

It  may  be  laid  down  as  a  rule  that  the 
simple  obstruction  of  excretory  passages 
leads,  not  to  fibrosis,  but  to  distension 
and  atrophy  of  the  cells  and  tissues  bor- 
dering upon  the  ducts,  and,  as  a  matter 
of  fact,  the  majority  of  cases  of  long- 
continued  biliary  obstruction  from  gall- 
stones or  from  pressure  upon  the  com- 
mon bile-duct  is  accompanied  by  no  ob- 
vious increa.sed  development  of  fibrous 
tifiBue  in  the  organ.    Certain  rare  cases, 


however,  do  occur  where  there  is  a  very 
characteristic  increase  in  the  connective 
tissue  around  the  bile-ducts  In  the  liver. 
Why  this  should  be  so  it  is  difficult  to 
explain,  unless  there  be  some  cause  over 
and  above  the  simple  obstruction.  What 
this  cause  is  is  Impossible  to  say,  because 
in  some  of  the  best-marked  early  cases — 
as,  for  example,  one  of  Kanthack  and 
Eolleston  and  another  of  Heneage 
Gibbes — the  condition  shows  Itself  in 
children  which  have  died  at  such  an 
early  age  that  the  condition  must  be 
regarded  as  congenital.  Possibly  some 
constituent  of  the  excreted  bile  acts  in 
these  cases  as  an  irritant. 

[Well-marked  cases  of  this  type  of 
cirrhosis  in  the  adult  are  distinctly  rare. 
That  of  Kelch  (Revue  de  M6d.,  p.  969, 
'81)  would  seem  to  be  the  first  surely 
of  this  nature.  Goluboff's  case  (Zeit.  f. 
klin.  Med.,  vol.  xxiv,  '94),  while  referred 
to  a  chronic  and  intermittent  gall-stone 
obstruction,  dating  back  for  11  years, 
was  anatomically  found  to  be  of  the  type 
to  be  immediately  dealt  with.  It  is  only 
to  be  expected  that  the  one  form  should 
pass  into  the  others.  One  of  the  best 
descriptions  of  the  condition  is  given  by 
Giggs  (Trans.  Path.  Soc,  London,  vol. 
xxxiv,  p.  129,  '83).  A  male  infant  began 
to  show  slight-yellowish  tingeing  of  the 
skin  and  jaundice  a  few  days  after  birth. 
The  jaundice  persisted,  but  was  never 
very  deep  in  color.  Nutrition  was  main- 
tained until  the  sixth  month,  when  wast- 
ing and  ascites  supervened,  the  child  dy- 
ing during  the  next  month.  The  liver  in 
this  case  was  hard  and  smooth;  there 
was  no  trace  of  the  common  duct;  the 
hepatic  duct  close  to  this  organ  was 
filled  by  a  fibrous  mass;  the  portal  vein 
was  nornuil.  With  these  appearances  it 
is  difficult  to  conipreliend  why  the  jaun- 
dice was  not  of  the  severest  typo.  Micro- 
scopically there  was  enormous  increase 
of  inlorlobuUir  connective  tissue  grow- 
ing ludiind  the  bile-duets  and  extending 
toward  the  junction  of  tlieso  with  tlio 
livcr-cellH.  1  have  been  indebted  to  Dr. 
RolIcHton   for  material   from   this   caae, 


CIRRHOSIS  OF  THE  LIVER.    BILIARY  CIRRHOSIS.    ETIOLOGY. 


229 


also  one  of  congenital  obstruction,  and  in 
this,  coupled  with  evident  dilatation  of 
the  intralobular  bile-capillaries,  there  was 
an  e.xquisite  development  of  fibrous  tis- 
sue, which  was  confined  to  the  imme- 
diate neighborhood  of  the  bile-ducts.  J. 
George  Adami.] 

In  all  such  cases  the  organ  is  enlarged, 
smooth,  and  fibrous,  and  progressive 
jaundice  is  the  leading  feature. 

2.  Biliary  Ciiieuosis  Phopee. 

Synonyms. — Hypertrophic  biliary  cir- 
rhosis; Hanot's  cirrhosis. 

So  long  ago  as  1857  Todd  drew  atten- 
tion to  the  fact  that  two  different  forms 
of  chronic  hepatitis  are  to  be  recognized, 
and  quoted  cases  of  enlarged  cirrhotic 
liver  without  ascites,  but  with  jaundice. 
Thus,  if  the  name  of  any  person  is  to  be 
associated  with  this  form  of  disease,  it 
would  be  that  of  Todd,  and  not  of  Hanot, 
who,  while  he  was  the  first  to  give  a  full 
study  of  this  form,  was  certainly  not  the 
first  to  clearly  draw  attention  to  its  ex- 
istence. In  1859  Charcot  and  Luys 
called  attention  to  the  fact  that,  in  some 
cases  of  cirrhosis  witli  enlarged  liver, 
the  new  fibrous  tissue  penetrates  into  the 
lobules  and  becomes  intralobular.  In 
1874  Hayem  reported  two  cases  of  cir- 
rhosis with  enlargement,  and  in  the 
same  year  Cornil  pointed  out  the  pres- 
ence of  groat  numbers  of  new  bile-ducts 
in  cases  of  cirrhosis  of  this  nature;  only 
in  the  following  year,  in  1875,  did 
Hanot's  well-known  thesis  appear  upon 
the  "Enlarged  Cirrhotic  Liver,"  in  which 
he  pointed  out  that  in  this  form  the  en- 
largement is  constant  throughout,  the 
surface  smooth,  and,  microscopically,  the 
cirrhosis  is  of  the  unilobular  type  and 
sometimes  pericellular,  with  a  plexus  of 
small,  new  bile-canaliculi;  while,  clinic- 
ally, he  showed  that  this  form  was  char- 
acterized by  permanent  jaundice  with- 
out ascites,  death  being  due  to  the  jaun- 
dice.    He   described   the   condition  as 


often  due  to  a  catarrhal  condition  of 
the  smaller  intrahepatic  bile-ducts.  The 
condition  is  a  rare  one,  though  each  year 
two  or  three  are  reported  in  the  journals. 
While  in  the  majority  of  cases  there  is 
a  definite  history  of  hard  drinking,  the 
more  recent  observations  of  Hanot  lead 
to  the  belief  that  the  disease  is  of  a  pos- 
sible infectious  or  microbic  origin. 

The  liver  in  these  cases  may  be  en- 
larged symmetrically  and  may  weigh  as 
much  as  eight  pounds. 

Observation  on  the  form  of  hyper- 
trophic cirrhosis  with  chronic  jaundice 
described  by  Hanot.  L  The  splenic  en- 
largement persists  unaltered  during  the 
whole  course  of  the  illness,  although  the 
variations  in  the  size  of  the  liver  may  be 
considerable  and  of  frequent  occurrence. 
2.  The  splenic  enlargement  precedes  the 
alterations  in  the  liver,  or,  at  least,  it 
precedes  the  outward  manifestations  of 
the  disease.  In  one  of  the  cases,  a  man 
who  died  at  about  30  of  this  form  of 
cirrhosis,  a  large  spleen  had  been  noted 
during  youth.  3.  The  disease  may  some- 
times occur  in  different  members  of  the 
same  family.  Children  of  patients  may 
have  a  large  spleen  without  any  other 
sign  of  the  affection.  In  one  family  the 
children  are  said  to  have  a  very  pig- 
mented skin,  and  this  has  been  observed 
likewise  in  some  collateral  branches  of 
the  family.  4.  The  large  spleen  may  be 
considered  as  the  essential  part  of  the 
disease.  5.  Although  ordinarily  malaria 
has  nothing  to  do  with  the  affection,  the 
cause  is  probably  analogous  to  that  of 
malaria  and  dependent  on  drinking- 
water.  6.  As  Hanot  and  Riener  ad- 
mitted, the  affection  seems  to  be  a  spe- 
cific one,  or,  at  least,  a  peculiar  infection 
of  the  spleen  and  liver,  not  a  simple  in- 
fection of  the  liver.  E.  Boix  (Presse 
MC-d.,  Mar.  16,  '98;  Brit.  Med.  Jour.,  May 
14,  '98). 

Etiology.- — In  tlie  first  place,  there  is 
a  marked  distinction  between  this  and 
ordinary  portal  cirrhosis,  in  that  it  af- 
fects young  adults.  By  far  the  greater 
number  of  cases  are  in  males  between 


230 


CIKKHOSIS  OF  THE  Ln^EE.    BILIAKY  CIRRHOSIS.    PATHOLOGY. 


the  ages  of  20  and  35.  Scliochman,  in 
the  26  cases  which  he  collected,  fonnd 
that  it  affected  22  males  and  4  females. 
In  the  majority  of  cases  there  is  a  definite 
history  of  hard  drinlcing;  but,  as  in 
other  cases  there  has  been  no  alcoholic 
history,  vre  must  conclude  that  alcohol  is 
not  the  immediate  cause.  So,  also,  ma- 
laria is  to  be  eliminated.  On  the  other 
hand,  there  is  increasing  evidence  at  the 
present  time — not,  it  is  true,  absolutely 
convincing — in  favor  of  regarding  this 
form  as  definitely  of  infectious  origin. 
In  favor  of  this  view  are  the  following 
facts: — 

1.  The  febrile  character  of  the  disease. 
As  Jaccoud  was  the  first  to  point  out,  the 
fever  may  reach  from  103°  to  103  ^/j"  F. 

2.  The  very  frequent  extension  of  the 
inflammation,  development  of  perihepa- 
titis, and  surrounding  adhesions. 

3.  The  condition  of  the  blood.  As 
Hanot  and  Meunier  have  sho^vn  (Soc.  de 
Biol,  de  Paris,  Jan.  25,  '95),  the  number 
of  white  corpuscles  in  the  blood  of  five 
cases  was  increased  from  13,000  to  20,000 
per  cubic  millimetre.  No  such  leucocy- 
tosis  is  observable  in  ordinary  portal 
cirrhosis. 

Hanot,  in  his  recent  communications, 
is  strongly  in  favor  of  the  infectious 
origin.  On  the  other  hand,  no  definite 
micro-organism  has  been  discovered, 
save  that  the  presence  of  the  colon  ba- 
cillus has  been  recognized  in  the  ducts 
upon  more  than  one  occasion.  The  fre- 
quency with  which  this  form  may  be 
present  in  the  gall-bladder  and  larger 
bile-ducts  and  there  set  up  mild  chronic 
disturbances  is,  nowadays,  being  more 
and  more  recognized. 

But  were  the  bacillus  coli  the  causative 
agent,  we  should  expect  to  find  the  dis- 
ease far  more  common  and  far  more 
frequently  associated  with  cholelithiasis. 


This  fatal  fovm  of  cirrhosis  is  pecul- 
iar to  the  Brahmin  children.     Brahmin 
women  in  childbed  adopt  a  diet  which 
may  conduce  to  the  disease  in  the  new- 
horn  infant,  in  whom  it  has  been  seen. 
They  restrict  themselves  to  the  use  of  a 
strong  decoction  of  black  pepper  to  allay 
thirst,    abstaining    from    liquid    of    any 
other  kind,  and  as  food  use  balls  made 
up  of  boiled  rice,  ghee,  and  coarse  sugar. 
E.  Mackenzie   (Lancet,  Feb.  2,  '95). 
Closely  allied  to  this  above  variety  of 
cirrhosis  is  the  "pericellular  cirrhosis" 
{vide  infra):  a  form  definitely  associated 
with  infection.     Hence,  on  the  whole, 
from  all  these  considerations  I  am  in- 
clined to  regard  this  provisionally  as  be- 
ing a  cirrhosis  of  infectious  origin. 

Pathology.— The  liver  is  sj'^mmetric- 
ally  enlarged  and  may  weigh  as  much  as 
eight  pounds;  it  is,  in  general,  smooth, 
herein  being  distinguished  from  portal 
cirrhosis;  more  frequently  in  that  dis- 
ease there  are  evidences  of  perihepatitis 
and  of  adhesions  to  the  diaphragm  and 
surrounding  viscera.  This  perihepatitis 
at  times  gives  a  very  liard  surface  to  the 
organ.  In  the  latter  stages  of  the  dis- 
ease, where  the  condition  has  been  of 
long  continuance  as  Goluboff  more  re- 
cently has  pointed  out  (Zeit.  f.  klin.  Med., 
vol.  xxiv,  '94),  there  may  be  a  certain 
amount  of  contraction  of  the  enlarged 
organ,  and  the  surface  may  take  on  a 
slightly-granular  appearance.  On  sec- 
tion, the  organ  cuts  very  firmly,  and  has 
an  intensely-jaundiced,  dark-green  ap- 
pearance; the  gall-bladder  is  full  of  bile 
of  good  color,  clearly  indicating  that 
there  is  no  absolute  obstruction  to  the 
flow  of  bile  from  the  organ,  while  the 
extrahepatic  bile-ducts  are  free  from  ob- 
struction. 

Microscopically,  the  appearance  is 
characteristic.  Frequently,  though  not 
always,  there  can  be  made  out  around  the 
larger  bile-ducts,  which  arc  very  prom- 
inent, a  more  or  less  concentric  over- 


CIRRHOSIS  OF  THE  LIVER.     BILIARY  CIRRHOSIS.     I'ATHULOGY. 


231 


growth  of  new,  fibrous  tissue,  and  this 
fibrosis,  instead  of  being  sharply  defined 
toward  the  lobules  of  the  organ,  invades 
them,  passing  between  the  cells;  so  that 
there  is  developed  a  pericellular  condi- 
tion. With  this  the  fibrosis  is  very  gen- 
eral, so  that  not  only  do  we  have  large 
bands  inclosing  several  lobules,  but  in 
addition  each  individual  lobule  tends  to 
be  surrounded,  and,  more  than  that, 
bands  of  the  new  tissue  may  actually  cut 
off  portions  of  lobules;  there  is  thus  de- 
veloped a  unilobular  cirrhosis,  as  con- 
trasted with  the  multilobular  appearance 
in  portal  cirrhosis.  Another  very  char- 
acteristic feature  of  the  condition  is  the 
appearance  of  the  new,  fibrous  tissue; 
this  tends  to  be  more  transparent  than, 
and  not  so  dense  as,  that  seen  in  the 
ordinary  portal  form,  while  it  is  perme- 
ated by  great  numbers  of  bile-canaliculi. 

Nature  and  distribution  of  the  new  tis- 
sue in  cirrhosis  of  the  liver:  1.  In  all 
forms  of  cirrhosis  the  white  fibrous  tis- 
sue is  increased.  2.  Along  with  the  in- 
crease of  white  fibrous  tissue  there  is  a 
new  formation  of  elastic  tissue.  This 
new  elastic  tissue  is  derived  from  -pre- 
existing tissue  in  the  adventitia  of  blood- 
vessels and  the  hepatic  capsules.  3.  Both 
white  fibrous  tissue  and  elastic  tissue,  in 
all  forms  of  cirrhosis,  may  penetrate  into 
the  lobules.  This  penetration  takes  place 
along  the  line  of  capillary  walls  or  fol- 
lows the  architecture  of  the  reticulum. 
The  chief  distinctions  between  the  histol- 
ogy of  atrophic  and  hypertrophic  cin'ho- 
sis  depend  upon  the  degree  of  extralobu- 
lar  growth  and  the  freedom  with  which 
the  lobules  are  invaded.  In  hypertrophic 
cirrhosis  there  would  appear  to  be  less  in- 
terlobular growth  and  an  earlier  and  finer 
intralobular  growtli.  4.  The  alteration.^ 
in  the  reticulum,  per  sc,  consist,  as  far  as 
can  be  made  out  at  present,  of  hyper- 
trophy rather  than  hyperplasia  of  the 
fibres.  It  is  still  uncertain  whether  any 
of  the  dilTerential  methods  now  in  fse 
suffice  to  distinguish  between  the  reticu- 
lum and  certain  fibres  derived  from  the 


white  fibrous  tissue  of  the  periphery  of 
the  lobules.  Simon  Flexner  (Univ.  Med. 
Mag.,  Nov.,  1900). 

As  to  the  nature  of  the  canaliculi, 
opinion  is  divided,  some  holding  them  to 
be  of  the  nature  of  new  formation  from 
the  pre-existing  bile-ducts,  others  hold- 
ing them  to  represent  a  late  stage  in  the 
atrophy  of  the  liver-cells.  My  own  ob- 
servations lead  me  strongly  to  support 
the  latter  view,  for,  in  several  sections  in 
which  they  have  been  abundant,  I  have 
clearly  made  out  the  transition  from  the 
liver-cell  to  bile-duct. 

From  comparative  anatomical  grounds 
this  would  seem  to  be  the  most  reason- 
able explanation  of  their  development. 
That  is  to  say,  that  following  the  suc- 
cessive stages  of  the  evolution  of  the  liver 
we  find  that  in  its  earliest  form  the  organ 
consists  of  a  mass  of  independent  finger- 
like  follicles.  Later  these  become  joined 
together  into  a  more  solid  mass,  and  with 
this  a  distinction  can  be  made  out  be- 
tween the  lower  duct-like  portions  and 
the  secretory  terminations  of  the  fol- 
licles. Later  again  the  cells  become  ar- 
ranged more  in  reference  to  the  blood- 
vascular  system  than  to  their  primary 
connection  as  members  of  separate  fol- 
licles. But  still  in  the  human  liver  the 
bile-capillaries  must  be  regarded  as  the 
representatives  of  the  lumina  of  separate 
hepatic  follicles,  and  in  peripheral 
atrophy  of  the  lobules,  where  that 
atrophy  is  not  extreme,  the  appearance 
which  these  sections  present  to  me  leads 
me  to  conclude  that  the  secreting  cells 
of  the  liver  undergo  what  I  have  else- 
where termed  "reversionary  degenera- 
tion" (vide  article  on  "Inflammation"  in 
volume  i  of  Allbutt's  "System  of  Medi- 
cine"). The  nuclei  proliferate,  and  in 
place  of  obscurely  arranged  masses  of 
typical  liver-cells,  we  obtain  small  rows 
of  cells  resembling  those  of  the  bile- 


232 


CIRRHOSIS  OF  THE  LIVER.     BILIARY  CIRRHOSIS.     SYMPTOMS. 


ducts,  with  whicli  they  become  continu- 
ous. 

[In  this  connection  it  is  interesting  to 
note  the  presence  of  tliese  new  bile-cana- 
liculi  in  cases  of  parenchymatous  hy- 
pertrophy occurring  in  connection  witli 
portal  cirrhosis  and  in  the  transitional 
eases  between  such  hypertrophy  and 
actual  adenomatous  development.  J. 
George  Adami.] 

The  general  appearance  of  the  larger 
bile-ducts,  their  abundant  and  proliferat- 
ing epithelium,  supports  the  view  of 
Goluboff  and  some  of  the  recent  French 
observers,  that  we  are  here  essentially 
dealing  with  a  chronic  diffuse  catarrhal 
angiocholitis  with  chronic  diffuse  peri- 
angiocholitis. At  the  same  time  it  may 
be  that  the  liver-cells  are  also  directly 
affected,  and  that  there  is  here  a  replace- 
ment-fibrosis  in  addition  to  the  inflam- 
matory, for  the  character  of  the  new 
connective  tissue,  especially  at  the  mar- 
gins of  and  invading  the  lobules,  is  not 
of  a  productive  inflammatory  type. 

With  regard  to  the  other  organs,  the 
spleen  is,  in  general,  enlarged,  and  some- 
times there  is  great  enlargement.  The 
lymph-glands  are  not  found  markedly 
enlarged;  the  kidneys  and  other  organs 
of  the  body  are  bile-stained,  but  beyond 
that  present  nothing  characteristic. 

Sjonptoms. — Pain  is  felt  in  the  region 
of  the  liver  of  a  dull  character,  with  some 
tenderness.  While  the  general  health  ap- 
pears to  be  fairly  good  and  the  appetite 
to  be  excellent,  there  is  a  slight  fever 
and  very  characteristic  is  the  develop- 
ment of  a  series  of  more  acute  attacks  of 
abdominal  pain  resembling  mild  hepatic 
colic,  associated  with  each  of  which  the 
jaundice  becomes  more  marked.  Gradu- 
ally the  abdomen  becomes  enlarged,  the 
enlargement  being  due  to  the  increased 
size  of  the  liver,  which,  on  palpation, 
presents  a  perfectly-smooth  surface.  Tlie 
process  is,  in  general,  of  slow  develop- 


ment; only  after  months  may  the  ab- 
domen become  markedly  enlarged,  and 
the  enlargement  may  slowly  continue  for 
as  many  as  eight  years;  but  the  jaundice 
is  progressive  and  becomes  so  intense 
that  the  skin  takes  on  a  dark-green  color. 
The  jaundice  is  not  obstructive,  as  shown 
by  the  fact  that  the  stools  continue  to  be 
stained.  The  urine,  according  to  Hanot, 
shows  slight  diminution  of  the  urea,  is 
high  colored,  and  contains  abundant  pig- 
ment. Throughout  the  disease  there  is 
absence  of  marked  ascites,  though  in 
some  cases  there  may  be  evidences  of 
intestinal  ha2morrhage.  Sometimes  there 
is  a  little  fluid  in  the  abdomen,  and  where 
this  is  the  case  it  would  seem  to  be  asso- 
ciated "nith  the  development  of  peri- 
hepatitis and  perisplenitis. 

As  the  disease  progresses,  there  is  loss 
of  strength,  and  with  the  progressive 
emaciation  petechiae  may  show  them- 
selves. Finally  coma  supervenes,  and 
death  occurs  directly  from  the  hepatic 
disturbance. 

Thus,  clinically  the  distinctions  be- 
tween this  form  of  cirrhosis  and  ordinary 
portal  cirrhosis  are: — • 

1.  The  life-period  at  wliicli  the  dis- 
ease develops. 

2.  The  enlargement  of  the  liver  and 
its  smooth,  or  but  slightly-roughened, 
surface  (from  perihepatitis). 

3.  The  persistent  jaundice. 

4.  The  characteristic  exacerbations  of 
hepatic  pain  and  of  jaundice. 

5.  The  absence  of  any  marked  ascites 
and  of  portal  obstruction,  save  at  the 
very  end. 

G.  The  preservation  of  an  excellent  ap- 
petite. 

7.  The  long  continuance  of  the  condi- 
tion after  the  recognition  of  the  first 
signs  of  hepatic  disturbance,  and,  asso- 
ciated with  this,  the  slow  emaciation  and 
the  retention  of  bodily  strength. 


CIRRHOSIS  OF  THE  LIVER.     BILIARY  CIRRHOSIS.    TREATMENT. 


233 


It  is  all  the  more  necessary  to  keep 
these  distinctions  in  view,  inasmuch  as 
there  is  the  painful  confusion  between 
this  true  biliary  cirrhosis  and  those  cases 
of  portal  cirrhosis  in  which  there  is  the 
enlarged  liver,  either  of  the  fatty  type  or 
again  of  the  mixed,  brought  about  by 
the  indiscriminate  employment  of  the 
term  "hypertrophic."  Nothing  has  more 
conduced  to  confusion  with  regard  to 
cirrhosis  than  the  employment  of  this 
term,  and  of  the  relative  term 
"atrophic." 

[Strictly  speaking,  the  term  hi/per- 
tropliy  of  the  liver  should  be  employed 
to  indicate  an  overgrowth  of  the  spe- 
cific liver-tissue, — i.e.,  of  the  parenchyma, 
— but  ought  never  to  be  employed  to  in- 
dicate the  overgrowth  of  the  connective 
tissue  of  the  organ,  or  the  mere  fact  that 
the  organ  is  enlarged.  In  short,  he  who 
wishes  to  make  himself  clearly  under- 
stood will  do  well  never  to  use  the  term 
in  connection  with  the  liver.  Similarly 
if  the  term  atrophic  be  banished  the 
unity  of  the  various  forms  of  portal  cir- 
rhosis will  be  better  grasped.  J.  George 
Adami.] 

Seven  cases  of  biliary  cirrhosis  in 
children,  presenting  all  the  symptoms  ob- 
sen'ed  in  the  adult,  but  with  the  addi- 
tion, in  many  cases,  of  hypertrophy  of 
the  spleen.  The  latter,  in  association 
with  biliary  cirrhosis,  is  peculiar  to  cases 
commencing  in  childhood.  In  some  in- 
stances the  ends  of  the  femur  and  tibia 
were  also  enlarged.  Gilbert  and  Fournier 
(Revue  Mensuelle  des  Mai.  de  I'Enfance, 
July,  '05). 

Case  of  Hanot's  hypertrophic  cirrhosis 
with  chronic  jaundice  in  which  a  very 
peculiar  attitude  of  the  body  developed. 
The  right  shoulder  was  lower  than  the 
left,  the  right  upper  limb  was  also  de- 
pressed, and  the  tip  of  the  right  middle 
finger  was  4  centimetres  below  the  cor- 
responding point  on  the  left  side.  The 
right  side  of  the  body,  as  a  whole,  was 
lower  than  the  left,  the  right  half  of  the 
pelvis  and  the  right  hip  being  depressed. 
The  right  gluteal  fold  was  2  centimetres 
below  that  on  the  left.     There  was  no 


spinal  cunature,  and  no  anatomical  le- 
sion to  account  for  it,  and  it  appeared 
to  be  purely  functional.  Sicard  and 
Remlinger  (Revue  de  M6d.,  Sept.,  '97). 

Diagnostic  points  insisted  on  in  cases 
of  hypertrophic  cirrhosis  with  icterus: 
(1)  enlargement  of  the  liver;  (2)  hep- 
atoptosis,  or  downward  displacement  of 
the  liver;  (3)  icterus;  (4)  discoloration 
of  the  faces.  In  similar  cases,  but  in 
which  the  fteces  retain  their  normal  color, 
Hanot's  disease  is  characterized  by  per- 
sistent jaundice,  enlarged  liver  (gradu- 
ally incieasing  and  slightly  tender  on 
pressure),  gieat  enlargement  of  the 
spleen,  no  clay  color  of  the  stools,  and 
no  ascites.  Leopold  L6vi  (Gaz.  d.  HOp., 
Feb.  2C,  '98). 

Prognosis. — To  the  best  of  our  knowl- 
edge this  disease  is  incurable,  although 
it  may  be  long  years  before  death  super- 
venes. A  few  cases  have  been  recorded 
in  which  death  has  been  of  an  acute 
course,  occurring  within  a  month.  In 
one  case  recorded  by  d'Espine,  in  an  in- 
fant, death  occurred  on  the  twenty-fifth 
day. 

Treatment. — AMiat  has  been  stated 
concerning  the  treatment  of  hepatic  cir- 
rhosis would  appear  to  apply,  in  a  large 
measure,  to  the  treatment  of  this  form. 
Special  care  must  be  taken  that  the  diet 
is  bland  and  imirritating,  because  in  se- 
vere cases  errors  in  diet  have  appeared 
to  induce  the  exacerbation  above  men- 
tioned. 

stress  laid  on  the  importance  and 
eflicacy,  at  the  outset,  of  calomel,  to- 
gether with  milk  diet.  In  the  biliary 
form  with  intense  jaundice,  injections  of 
salicylate  of  sodium,  15  to  30  grains  to 
1  pint  of  water,  to  be  repeated  daily.  In 
addition,  massage  of  the  liver,  chola- 
gogues,  appropriate  diet,  hot  baths  (with 
massage  in  the  bath),  and  a  course  at  an 
alkaline  spring.  Liebreich  (Practitioner, 
Apr.,  '94). 

Two  cases  of  biliary  hypertrophic  cir- 
rhosis of  the  liver  wliich  recovered  in 
consequence  of  operation.    In  the  firat 


234 


CIRRHOSIS  OF  THE  LR^ER.    PERICELLULAR  CIRRHOSIS. 


case  the  operation  was  accidentally  un- 
dertaken; that  is,  it  was  due  to  a  mis- 
taken diagnosis.  The  result  in  this  fii'st 
case  was  so  satisfactory  that  operative 
intervention  was  deliberately  under- 
taken in  the  second  case.  The  oper- 
ation the  author  recommends  for  this 
condition  consists  in  sewing  the  omen- 
tum, gall-bladder,  and  liver  to  the  pa- 
rietal peritoneum.  The  author  advances 
a  tentative  theory  to  account  for  the 
favorable  results  observed.  The  opera- 
tion is  in  itself  comparatively  harmless, 
and,  in  the  author's  opinion,  deserves  a 
further  trial.  Rosenstim  (Medical  Rec- 
ord, Xov.  7,  1903). 

Pericellular  Cirrhosis. 

As  already  stated,  the  condition  of 
pericellular  cirrhosis  exists  to  some  ex- 
tent in  biliary  cirrhosis,  and  in  the  so- 
called  mixed  type  of  portal  cirrhosis  a 
certain  amoimt  of  pericellular  or  mono- 
lobular  deposit  of  connective  tissue  is 
to  be  recognized.  But  there  exist  cases 
in  which  the  pericellular  change  is  mi- 
croscopically the  most-marked  alteration 
in  the  organ,  and,  inasmuch  as  these 
cases  are,  in  general,  unaccompanied  by 
either  jaundice  or  ascites,  it  becomes 
necessary  to  treat  them  as  a  separate 
class. 

We  rarely,  in  the  adult,  meet  with  a 
generalized  form  of  the  disease.  The 
most  frequent  examples  are  to  be  met 
with  in  the  infant  in  connection  with 
congenital  syphilis.  Not  infrequently 
it  is  to  be  found  well-marked  in  children 
bom  prematurely,  whether  alive  or  dead, 
close  upon  term.  It  may,  however,  be 
very  evident  during  the  first  months  of 
extra-uterine  life,  and  where  this  is  the 
case  it  often  indicates  a  syphilitic  in- 
toxication 60  severe  as  to  lead  to  death 
before  the  end  of  six  months;  rarely  do 
the  children  survive  if  the  hepatic  en- 
largement is  very  extensive.  Occasion- 
ally, however,  there  may  be  this  diffuse 
pericellular  cirrhosis  in  the  adult,  pos- 


sibly, according  to  some  writers,  among 
whom  may  be  mentioned  Tzeytliue 
(These  de  Paris,  '96),  of  the  nature  of 
a  delayed  hereditary  syphilis,  in  which 
case  it  is  associated  with  the  presence  of 
gummata;  in  other  cases  too,  more 
rarely,  it  is  a  manifestation  of  acquired 
tertiary  syphilis.  I  have  seen  one  case 
of  this  in  which  in  addition  to  the  pres- 
ence of  numerous  well-marked  gummata, 
there  was  this  general  pericellular  devel- 
opment of  delicate  connective  tissue  with 
signs  of  progressive  atrophy  of  the  liver- 
cells.  In  this  case,  however,  while  the 
process  was  diffuse,  it  was  most  advanced 
in  the  neighborhood  of  the  gummata, 
and  there  were  areas  in  the  liver  showing 
relatively  little  fibroid  change.  Very 
rarely  in  tuberculosis  there  may  be  a 
similar  pericellular  change,  though  not 
so  extensive  as  in  syphilis. 

In  cattle,  as  first  pointed  out  by 
Wyatt  Johnston  (Transactions  of  the 
American  Veterinary  Association,  '93, 
and  Appendix  to  Report  of  the  Minister 
of  Agriculture  for  the  Dominion  of 
Canada,  '93),  there  exists  in  a  strictly- 
limited  region  of  Nova  Scotia,  around 
Pictou,  a  disease  among  cattle  character- 
ized by  very  extensive  cirrhosis.  The 
disease  appears  to  be  chronic,  and  death 
occurs  after  a  brief  period  of  acute 
delirium  or  from  a  progressive  paresis 
pa.ssing  on  to  complete  paralysis  with 
stupor.  The  disease  most  often  is  first 
recognized  by  the  acrid  taste  and  odor 
of  the  milk,  which  rapidly  diminishes  in 
amount,  and  with  this,  or  earlier,  the 
coat  becomes  "staring,"  the  eyes  promi- 
nent and  very  bright,  and  there  is  con- 
siderable looseness  of  the  bowels.  There 
is  no  jaundice  and  but  a  slight  accumu- 
lation of  fluid  in  the  abdominal  cavity 
toward  the  later  stages.  Upon  killing 
the  animal  the  main  pathological 
changes    are,    in    general,    a    moderate 


CIRRHOSIS  OF  THE  LIVER.    PERICELLULAR  CIRRHOSIS. 


235 


enlargement  of  the  liver  with  some 
obtuseness  of  the  angles;  the  surface  is 
perfectly  smooth.  Microscopically  there 
is  marked  evidence  of  parenchymatous 
and  fatty  degeneration  of  the  cells,  great 
diminution  in  their  number,  and  replace- 
ment by  a  delicate  and  very  transparent 
connective  tissue,  which  in  more  ad- 
vanced cases  is  to  be  found  more  dense 
and  more  concentrated  around  the  intra- 
hepatic bile-ducts.  There  is  no  Jaun- 
dice; indeed,  in  the  twenty  or  so  autop- 
sies which  were  performed  in  this  dis- 
ease the  gall-bladder  was,  in  general, 
very  full  of  bile  or  light  color,  the  faeces 
were  well  stained,  and,  if  anything,  there 
appeared  to  be  an  excessive  excretion 
from  the  organ. 

Other  well-marked  features  are  the 
presence  of  a  clear,  limpid  fluid  in  the 
abdomen  (though  this  ascites  is  never 
excessive),  a  moderate  enlargement  of 
the  abdominal  lymphatic  glands  and  of 
the  glands  at  the  hilus  of  the  liver,  and 
a  peculiar  gelatinous  cedema  of  the  coats 
of  the  fourth  stomach  and  small  intes- 
tines and  of  the  mesenteries.  In  the 
fourth  stomach,  also,  there  are  numerous 
follicular  ulcers,  generally  found  in  a 
cicatrized  condition.  Studying  this  dis- 
ease I  constantly  came  across  a  minute 
bacillus  presenting  polar-staining,  cult- 
ures of  which  were  fatal  to  rabbits, 
guinea-pigs,  and  mice  at  periods  varying, 
in  rabbits,  from  a  fortnight  to  a  month, 
though  in  these  cases  the  liver  showed 
parenchymatous  degeneration  and  al- 
most singularly-slight  early  cirrhosis. 

In  some  isolated  regions  in  Germany 
and  Switzerland  the  horses  are  said  to 
BufTcr  from  a  similar  enzootic  cirrhosis. 

Anatomical  Changes. — Leaving  aside 
these  cases  of  pericellular  cirrhosis  of 
the  lower  animals,  and  referring  more 
especially  to  the  liver  of  congenital  syph- 
ilis in  the  infant,  the  organ  here  is  found 


very  greatly  enlarged,  so  that  in  some 
cases  its  edge  may  reach  to  the  iliac 
crest;  the  surface  is  smooth  and  of  a 
deep-red  color,  though  I  have  come 
across  cases  in  which  there  was  a  coarsely- 
mottled  appearance  of  relatively-large 
areas  of  bright-yellow  color  standing  out 
against  the  red.  Upon  section  the  organ 
is  fairly  firm,  and,  microscopically,  the 
main  feature  is  this  infiltration,  between 
the  hepatic  cells,  of  delicate  connective 
tissue  with,  however,  a  fair  infiltration 
of  small,  round  cells,  the  hepatic  cells 
showing  evidences  of  marked  atrophy. 
The  portal  sheaths  are  also  greatly  en- 
larged, and  present  considerable  infiltra- 
tion with  small,  round  cells.  There  are, 
in  general,  evidences  of  the  existence  of 
miliary  gummata,  as  minute  small  col- 
lections of  round  cells  not  very  sharply 
defined  are  scattered  irregiUarly  through 
the  organ;  only  in  rare  cases  has  the 
presence  of  occasional  caseous  gummata 
been  noted. 

According  to  Hochsinger,  four  distinct 
main  anatomical  changes  can  be  made 
out:  1.  Diffuse  small-celled  infiltration. 
2.  Connective-tissue  hyperplasia.  3. 
Miliary  gummata.  4.  Very  rarely  true 
nodular  gummata. 

Taking  all  these  cases  together,  it  is 
evident  that  this  condition  is  distinctly 
of  infectious  origin,  due,  perhaps,  not 
so  much  to  the  direct  proliferation  of  the 
bacteria,  for  where  that  is  the  case,  as 
in  tuberculosis  and  syphilis,  there  is  ac- 
cumulation of  small,  round  cells  at  the 
various  foci  of  proliferation,  but  due  to 
a  toxic  effect  of  the  bacteria  upon  the 
liver-cells,  the  development  of  the  fibrous 
tissue  being  secondary  to  the  atrophy  of 
the  parenchyma. 

Experimentally,  according  to  Au- 
frecht,  a  somewhat  similar  interstitial  or 
pericellular  cirrhosis  is  producible  by 
the  action  of  small  doses  of  phosphorus 


236 


CIRRHOSIS  OF  THE  LIVEK.     PEKICELLULAK.    ARTERIAL. 


frequently  repeated.  Such  minute  doses 
do  not,  like  larger  ones,  lead  to  com- 
plete necrosis  of  the  liver-cells,  but  the 
protoplasm  becomes  paler,  the  nuclei 
more  evident  and  closer  together,  and 
the  cirrhosis  is  diffuse  and  interstitial, 
exclusively  due  to  the  diseased  hepatic 
cells  more  especially  at  the  periphery  of 
the  acini.  As  is  to  be  expected,  poisons 
introduced  into  the  system  from  without 
act  like  those  developed  within  the  or- 
ganism (using  this  term  in  its  broadest 
sense);  so  that  some  act  primarily  upon 
the  intestinal  walls  and  only  secondarily 
upon  the  liver;  others  act  directly  upon 
the  hepatic  parenchyma,  while  all  vary 
in  their  action  according  to  their  con- 
centration. 

Diffuse  "interstitial  hepatitis,"  leading 
to  cirrhosis,  is  never  the  result  of  an  in- 
terstitial inflammation;  it  depends  en- 
tirely on  an  inflammatory  process,  affect- 
ing the  glandular  cells  of  the  peripheral 
parts  of  the  acini.  Human  cirrhosis  cor- 
responds e.xactly  with  experimental  cir- 
rhosis as  produced  by  phosphorus.  Au- 
frecht  (Deut.  Arch.  f.  klin.  Med.,  vol. 
Iviii,  p.  302,  '97). 

Symptoms  (Syphilitic  Pericellular  Cir- 
rhosis).— There  seem  no  recognizable 
symptoms  of  this  condition  beyond  the 
extreme  enlargement  of  the  liver,  which 
is  tender,  and  the  co-existence  of  other 
evidences  of  the  disease.  There  is,  as 
above  said,  no  ascites  and  no  jaundice. 

As  above  stated,  this  variety  of  cir- 
rhosis frequently  leads  to  intra-uterine 
death  and  to  premature  birth,  and,  where 
the  child  survives  birth,  death  in  general 
occurs  before  the  sixth  month.  Where 
the  enlargement  of  the  liver  is  extensive, 
there  appears  to  be  little  chance  of  re- 
covery, though  mercurial  treatment  has 
resulted  in  some  recoveries. 

Hochsinger  (Zur  Kenntniss  des  Ange- 
borenen  Lebersyphilis  dcr  Siiuglinge," 
Vienna,  '90)  states  that  of  148  infants 


with  congenital  syphilis,  46  showed  clin- 
ical enlargement  of  the  liver.  The  large 
number  of  30  of  these  are  stated  to  have 
recovered.  Five  cases  came  to  autopsy, 
and  in  1  the  enlargement  was  due  to 
tuberculosis.  In  none  of  his  cases  was 
there  icterus  or  jaundice;  in  these  en- 
larged livers  there  was  some  extent  of 
fat-infiltration.  He  is  strongly  in  favor 
of  immediate  mercurial  treatment. 

Arterial  Cirrhosis. 

Contrary  to  what  I  believe  is  the  gen- 
erally-received opinion,  I  find  that  in 
cases  of  general  arteriosclerosis  branches 
of  the  hepatic  arteries  resemble  other 
arteries  throughout  the  body  in  showing 
a  distinct  periarteritis 

[Recently  Hasenfeld  (D.  Arch.  f.  klin. 
Med.,  '97)  has  noted  similarly  a  slight 
chronic  endarteritis  in  the  hepatic  ar- 
teries in  arteriosclerosis.  J.  George 
ADAin.] 

This  periarteritis  is  rarely  extreme 
and  clinically  is  incapable  of  recogni- 
tion, though  Eichhorst  is  inclined  to 
recognize  a  senile  variety  of  cirrhosis 
due  thereto,  and  analogous  to  the  arte- 
riosclerotic nephritis  resulting  from  ar- 
teritis and  periarteritis  in  the  renal  ves- 
sels. This  arterial  change  is  only  of 
interest  in  that  a  large  proportion  of 
subjects  with  alcoholic  cirrhosis  present 
also  a  condition  of  general  arteriosclero- 
sis, and  thus  associated  with  alcoholic 
cirrhosis  there  may  be  independently  a 
certain  amount  of  fibroid  development 
in  the  portal  sheaths  due  to  tlie  arterial 
disturbance. 

Certain  writers  have  suggested  that 
the  toxic  substance  leading  to  the  devel- 
opment of  what  I  have  termed  "portal 
cirrhosis"  are  brought  to  the  organ  by 
the  arterial  branches;  if  this  be  so,  the 
anatomical  evidence  of  the  transmission 
is  singularly  small. 


CIRRHOSIS  OF  THE  LIVER.    CENTRILOBULAR.     SECONDARY. 


237 


Centrilobular  Cirrhosis. 

In  cases  of  well-marked  obstructive 
disease,  either  of  the  heart  or  of  the 
lungs,  the  liver  is  the  seat  of  great, 
passive  congestion,  with  atrophy  of  the 
central  cells  of  the  lobule.  There  is  no 
sign  of  fibroid  development  in  these  re- 
gions; all  that  is  to  be  seen  is  the  great 
dilatation  of  the  central  capillaries  of 
the  lobule,  with  atrophy  of  the  cells. 
In  cases  of  a  more  chronic  type  with 
less  severe  obstructive  disease  we  occa- 
sionally meet  with  a  well-marked  devel- 
opment of  fibrous  tissue  immediately 
round  the  central  vein  of  the  lobule.  It 
is  debatable  whether  this  is  of  the  nature 
of  a  replacement-fibrosis  in  consequence 
of  the  atrophy  of  the  central  liver-cells 
or  whether  it  may  be  termed  "non-func- 
tional" or  "non-inflammatory,"  due  to 
the  increased  pressure  in  the  hepatic 
veins  and  the  altered  character  of  the 
blood-flow.  This  form,  again,  while  it 
may  be  predicated  in  cases  of  long-con- 
tinued slight  mitral  or  other  obstructive 
disease,  is  associated  with  no  clinical 
symptoms. 

Hanot  and  Gilbert  have,  however,  de- 
scribed a  venous  "hypertrophic"  liver 
with  enlargement,  the  organ  remaining 
enlarged.  If  this  form  truly  exists,  it 
will  be  clinically  impossible  to  differ- 
entiate it  from  the  enlargement  due  to 
accompanying  passive  congestion. 

Secondary  Cirrhosis. 

Synonyms. — Cirrhosis  following  upon 
perihepatitis;  Glissonian  cirrhosis;  zuck- 
erguss  leber. 

While  chronic  perihepatitis  may  either 
be  localized,  and  in  patches  over  the 
surface  of  the  liver,  or  generalized,  it  is 
with  the  generalized  form  that  we  have 
to  deal  in  an  article  on  "cirrhosis." 
Such  generalized  perihepatitis  is  a  very 
characteristic  condition  pathologically, 
though  clinioflllv  it  may  be  present  in  an 


advanced  form  without  any  signs  of  its 
presence,  and,  on  the  other  hand,  may 
ape  and  be  almost,  if  not  quite,  indis- 
tinguishable from  the  atrophic  and  con- 
tracted form  of  portal  cirrhosis. 

Etiology.  —  Such  thickening  of  the 
capsule  of  the  liver  may  be  one  of  the 
results  of  a  general  peritonitis;  indeed, 
it  must  be  regarded  as  one  evidence  of 
such  a  condition. 

Of  22  cases  of  universal  perihepatitis 
in  the  post-mortem  records  at  Guy's 
Hospital  collected  by  Hale  White  (All- 
butt's  "System  of  Medicine,"  volume  v, 
p.  lis),  in  only  2  was  it  stated  there  was 
no  peritonitis;  in  17  it  was  distinctly 
stated  to  be  present,  and  in  the  remain- 
ing 3  no  mention  was  made  of  the  peri- 
toneum. Hale  White  suggests  that  in 
his  cases  the  peritonitis  was  always 
fibroid  and  so  never  owed  to  tubercular 
growth;  this,  however,  is  contrary  to 
the  observations  of  other  writers,  and 
I  myself  have  seen  a  most-marked  con- 
dition of  universal  perihepatitis  accom- 
panying and  evidently  due. to  a  chronic 
peritoneal  tuberculosis,  though  it  is  true 
the  thickened  capsule  in  such  case  does 
not  show  a  characteristically  tubercular 
appearance  throughout,  but  is  fibroid  in 
its  deeper  layers  and  homogeneous.  But 
a  study  of  chronic  tuberculous  pleurisy 
shows  that  the  process  may  assume  this 
homogeneous  fibroid  character.  In  fact 
it  may  be  said  that  this  form  of  universal 
fibrous  perihepatitis  is  distinct  from  lo- 
calized chronic  perihepatitis  in  that  it 
is  an  extension  of  inflammatory  disturb- 
ance from  without  the  liver,  and  not 
from  within,  as  may  often  happen  in  the 
latter  condition,  and  that  anything  ca- 
pable of  setting  iip  a  chronic  productive 
inflammation  in  the  abdominal  cavity  is 
also  capable  of  producing  this  form  of 
disease. 

Pathological    Anatomy.  —  Tn    conse- 


238 


CIRRHOSIS  OF  THE  OVER.    SECOXDARY  CIRRHOSIS.    SYMPTOMS. 


quence  of  the  deposit  of  this  thickened, 
new,  fibrous  tissue  over  the  surface  of 
the  organ  and  its  contraction,  the  liver 
becomes  more  globular  in  appearance 
than  normal,  though  it  is  to  be  noticed 
that,  in  general,  the  thickening  is  more 
marked  on  the  upper  and  anterior  sur- 
face than  on  the  under  surface.  Fre- 
quently, as  Fagge,  I  believe,  was  the 
tirst  to  point  out,  the  anterior  edge  is 
folded  over  on  to  the  dorsum  in  a  man- 
ner that  is  difficult  to  explain.  Fre- 
quently, also,  the  omentum,  shortened 
and  thickened  by  the  universal  peri- 
tonitis, is  adherent  to  the  lower  edge 
of  the  organ;  and  this  thickened  mass 
may  be  mistaken  for  the  edge  of  the 
liver.  Frequently,  again,  the  productive 
inflammation  on  the  surface  leads  to  ad- 
hesions, more  especially  anteriorly  and 
to  the  diaphragm. 

As  Hale  \Vhite  points  out,  often  little 
pits  are  to  be  seen  on  the  surface  of  the 
thickened  capsule;  when  seen  they  are 
very  striking.  I  have  only  seen  them 
upon  the  upper  diaphragmatic  aspect  of 
the  organ  in  regions  where  there  have 
been  no  adhesions,  and  from  their  posi- 
tion and  character  I  am  inclined  to  be- 
lieve that  they  are  brought  about  by 
little  eddies  opposite  to  the  lymph-stig- 
mata in  the  under  surface  of  the  dia- 
phragm. A  marked  feature  is  the  ease 
with  which  the  thickened  capsule  can  be 
peeled  off,  leaving,  in  general,  a  smooth 
surface. 

Authorities  diifur  as  to  tlie  connection 
between  this  perihepatitis  and  cirrhotic 
change  in  the  organ  itself.  According 
to  Murchison  and  Osier,  it  is  frequent, 
but  Fagge,  Hale  White,  and  Cursch- 
mann  (Deut.  mcd.  Woch.,  p.  564,  '84) 
speak  of  the  condition  as,  in  general, 
unaccompanied  by  any  interstitial  in- 
flammation. And,  in  the  not  very  fre- 
quent cases  which  I  have  come  across, 


I  also  have  found  the  liver  soft  and 
pulpj',  rather  than  fibroid.  Evidently 
both  conditions  may  exist,  and,  speaking 
correctlj',  it  is  only  the  former  condi- 
tion where  there  is  this  extension  of  the 
inflammatory  process  inward  along  the 
lymphatics,  leading  to  the  development 
of  fibrous  bands  within  the  organ;  or, 
again,  where  there  is  an  extension  up- 
ward of  the  process  into  the  organ  along 
the  sheaths  of  the  portal  vessels  at  the 
hilus,  which  ought  properly  to  be  spoken 
of  as  cirrhosis. 

With  regard  to  other  organs.  The 
spleen,  in  general,  shows  a  like  capsular 
thickening,  more  especially  of  its  dia- 
phragmatic surface,  and,  as  Hale  White, 
who  has  made  the  fullest  study  of  the 
condition,  points  out,  there  is  a  very  fre- 
quent complication  of  interstitial  ne- 
phritis. 

Symptoms.  —  Frequently,  as  above 
stated,  there  are  no  symptoms  recog- 
nizable; but,  in  a  typical  condition  of 
the  disease,  we  find  the  liver  smaller 
than  normal,  with  thickened  uniformly 
blunt  edge,  and,  associated  with  this, 
marked  ascites. 

Hale  White  points  out  that  the  condi- 
tion is  of  long  duration,  and  that  the 
ascitic  fluid  can  be  repeatedly  tapped. 
There  is  an  absence  of  jaundice,  while 
evidences  of  chronic  peritonitis  and, 
again,  of  interstitial  nephritis,  are  well 
marked. 

At  times  a  friction-sound  can  be  made 
out  over  the  liver,  though  this  is  rare; 
more  frequently  the  organ,  by  adhesions 
to  the  abdominal  wall,  becomes  fixed  and 
it  docs  not  move  downward  on  inspira- 
tion. 

Tn  TjoikIdii  apparently  this  condition 
is  fairly  frequent,  for  Fagge  makes  the 
statement  that,  at  Guy's  Hospital,  for 
every  five  cases  that  die  showing  portal 
cirrhosis   with   ascites  there   is   one   in 


CIRRHOSIS  OF  THE  LIVER.    SPORADIC  CIRRHOSIS. 


239 


which  the  ascites  is  associated  with  peri- 
hepatitis. 

Treatment. — Where  there  is  such  ex- 
tensive perihepatitis,  treatment  cannot 
be  curative,  but  can  only  be  palliative, 
and,  of  palliative  measures,  tapping  is 
the  most  important. 

Sporadic  Cirrhosis. 

I  would  employ  the  term  "sporadic 
cirrhosis"  to  indicate  those  cases  in 
which  there  is  a  fairly-extensive  devel- 
opment of  fibrous  tissue  throughout  the 
liver  in  scattered  patches  related  defi- 
nitely in  origin  to  no  one  special  portion 
of  the  lobule  or  of  its  surrounding 
sheath.  Where  the  development  is 
slight,  we  can  scarcely  speak  of  cirrhosis; 
but  in  some  cases  the  connective-tissue 
development  may  be  very  extensive,  and 
here  we  must  speak  of  cirrhosis. 

Two  main  series  of  cases  are  to  be  in- 
cluded under  this  heading: — 

1.  The  fibrous-tissue  development  in 
consequence  of  the  presence  of  multiple 
infectious  granulomata:  a  condition  seen 
in  tuberculosis  and  syphilis. 

2.  The  condition  to  which  our  atten- 
tion has  been  more  especially  directed 
by  Welch,  Flexner,  Barker,  and  the 
Johns  Hopkins  School,  in  which,  ap- 
parently from  the  action  of  toxins  rather 
than  from  bacteria,  multiple  focal  ne- 
croses are  developed  in  the  liver.  These 
focal  necroses  pass  through  the  success- 
ive stages  of  slow  death,  infiltration  with 
leucocytes,  and  organization  and  forma- 
tion of  fibrous  tissue,  leading  eventually 
to  the  development  of  fibrous  tissue; 
so  that  scattered  through  the  organ  are 
little,  irregular  nodules  of  fibrosis. 

Yet  a  third  form  may  be  recognized, 
for  the  recognition  of  which  we  are  again 
indebted  to  Welch,  namely:  that  form  of 
cirrhosis  due  to  the  conveyance  into  the 
liver  by  lymph  or  blood  of  discrete  par- 
ticles of  foreign  matter,  as,  for  example, 


of  carbon  or  of  stone.  Around  about 
such  little  collections  of  foreign  particles 
there  may  be  developed  here,  as  in  the 
lung,  a  noticeable  amount  of  fibrous  tis- 
sue; but,  in  general,  the  condition  is 
very  slight. 

I  have  come  across  it  both  in  connec- 
tion with  anthracosis  and  again  in  con- 
nection with  stone-mason's  lung,  or  sili- 
cosis; but  to  the  best  of  my  belief 
Welch's  well-known  case  of  cirrhosis 
anthracotica  is  the  only  very  extensive 
and  truly  cirrhotic  case  upon  record. 

1.  Cirrhosis  Due  to  Infectious 
Granulomata. — In  general,  tubercu- 
losis affecting  the  liver  leads  to  no  recog- 
nizable sjTnptoms,  even  though  the  liver 
be  thickly  studded  throughout  with 
fibroid  tubercles;  very  rarely  we  have  a 
caseous  mass.  Beyond,  therefore,  men- 
tioning the  existence  of  this  form,  it  is 
unnecessary  for  me  to  say  an3'thing  fur- 
ther concerning  it. 

With  syphilis  it  is  different.  Here 
dense  bands  of  new  tissue  may  radiate  in 
various  directions  around  the  fibroid  and 
caseous  gummata.  Wliere  these  gum- 
mata  are  frequent,  the  obstructive  effect 
of  the  bands  and  again  the  deformity  of 
the  organ  may  lead  to  signs  and  symp- 
toms which  closely  simulate  either  the 
atrophic  or  parenchymatous  hypertro- 
phic form  of  portal  cirrhosis.  But  even 
in  the  most  extensive  cases  the  develop- 
ment of  this  fibrous  tissue  is  so  sporadic, 
and  the  condition  of  the  other  parts  of 
the  organ  is  so  relatively  healthy,  that, 
strictly  speaking,  these  cases  ought  not 
to  be  spoken  of  as  cirrhotic. 

For  its  symptomatology,  this  gumma- 
tous form  depends  upon  the  number  and 
the  position  of  the  gummatous  growths 
in  the  organ  and  the  amount  of  fibrosis 
developed  in  the  immediate  neighbor- 
hood. As  these  gummata  have  no  points 
of  election  and  may  occur  on  the  upper 


240 


CIRRHOSIS  OF  THE  UVER.    SPORADIC  CIRRHOSIS. 


surface  and  away  from  the  vessels  at 
the  hilus  as  frequently  as  they  occur 
in  its  neighborhood,  it  follows  that  we 
may  have,  on  the  one  hand,  an  advanced 
gummatous  condition  of  the  organ  un- 
accompanied by  jaundice  or  by  ascites 
or  by  any  recognizable  disturbance; 
while,  on  the  other  hand,  there  may  be 
but  a  few  gummata,  and  yet  these,  being 
situated  in  such  a  position  as  to  obstruct 
either  the  main  branches  of  the  portal 
vein  or  some  of  the  main  bile-ducts 
within  the  organ,  may  induce  either  as- 
cites or  icterus,  or  both.  In  advanced 
cirrhosis,  where  there  are  numerous 
gummata,  it  may  be  possible  to  palpate 
the  lower  portion  of  the  organ,  and  to 
recognize  the  scarred  and  coarsely-nodu- 
lar condition  of  the  surface;  or,  again, 
as  in  advanced  portal  cirrhosis,  the  or- 
gan may  be,  by  the  contraction  of  the 
fibrous  tissue,  so  retracted  behind  the 
ribs  as  to  be  incapable  of  being  felt. 
■^Tiere  this  is  the  case,  it  is  impossible 
to  make  a  diagnosis  between  tertiary 
syphilis  and  the  liver  of  alcoholic  cir- 
rhosis, unless  the  evidence  of  syphilitic 
infection  of  other  organs  is  present. 
Where  there  is  doubt  as  to  the  nature 
of  the  condition,  progressive  improve- 
ment manifested  under  the  potassium- 
iodide  treatment  will  clear  up  the  diag- 
nosis. Osier  distinguishes  a  group  of 
cases  in  which  the  patient  is  ana3mic, 
and  passes  large  quantites  of  pale  urine 
containing  albumin  and  tube-casts;  the 
liver  is  enlarged  and,  perhaps,  irregu- 
lar; and  the  spleen  also  is  enlarged; 
while  ascites  may  supervene.  In  such  a 
case  the  presence  of  gummata  is  asso- 
ciated with  amyloid  degeneration  of  the 
organ,  of  the  intestinal  mucosa,  and  of 
the  spleen.  He  further  points  out  what 
is,  perhaps,  not  very  uncommon:  that 
the  large  projecting  masses  of  liver- 
tissue  produced  by  the  contraction   of 


gummata  affecting  the  left  lobe  are  apt 
to  be  mistaken  for  new  growths  occur- 
ring in  connection  with  the  organ.  Here, 
again,  potassium  iodide  affords  valuable 
aid  in  diagnosis. 

In  brief,  the  history  of  syphilitic  in- 
fection, and  the  effects  of  treatment  by 
potassium  iodide,  are  the  main  diag- 
nostic aids  in  differentiating  syphilitic 
or  other  forms  of  cirrhosis. 

2.  The  Cirrhosis  of  Focal  Ne- 
croses.— As  yet  we  know  and  patholog- 
ically have  been  able  to  recognize  singu- 
larly few  cases  of  cirrhosis  originating 
from  focal  necroses.  Such  focal  necroses 
occur  in  a  large  number  of  infectious  dis- 
eases. Not  only  have  they  been  recog- 
nized by  Welch  and  Flexner  in  diph- 
theria, by  Eeed  and  subsequent  observers 
in  typhoid  fever,  and  by  numerous  ob- 
servers in  tuberculosis,  but  by  Guarnieri, 
Thayer  and  Hewetson,  Barker,  and 
others  in  malaria;  and  Flexner,  in  his 
experimental  work  upon  toxalbumins, 
has  been  able  to  show  that  several  vege- 
table poisons  of  the  nature  of  toxal- 
bumins will  produce  them  and  follow  the 
development  of  cirrhosis  following  upon 
these  focal  necroses. 

[Haiiot  (Coniptes-rcndus  de  la  Soc.  do 
Biol.,  p.  4G9,  '93)  desciibcs  as  tachcs 
blanches  du  fiiie  infcctioux  certain  ap- 
pearances wliicli,  he  points  out,  charac- 
terize the  liver  in  all  forma  of  infectious 
disease;  small  irregular  areas  of  palo 
color,  appearing  more  especially  on  the 
convex  surface,  in  which  upon  micro- 
scopical examination  a  condition  of  di- 
lated capillaries  with  abundant  intra- 
vascular and  extravascular  leucocytes  are 
to  be  made  out.  The  liver-cells  in  the 
regions  show  degenerative  changes.  The 
condition  is  allied  to  the  focal  necrosos. 
J.  Georoe  AnAMr.] 

As  to  the  exact  causation  of  the  ne- 
croses, some  doubt  must,  I  think,  still  be 
expressed.  While  it  is  possil)le  that,  as 
many  observers  believe,  they  are  directly 


CLITORITIS.    SYMPTOMS. 


241 


due  to  the  action  of  toxins,  it  is  difficult 
to  comprehend  why  such  toxins  should 
pick  out  only  specially-isolated  portions 
of  the  organ.    One  would  expect  to  find 
that  in  addition  to  the  action   of  the 
toxins  there  is  some  disturbance  of  the 
circulation,  some  thrombosis,  or  other 
change  in  the  smaller  veins  or  capillaries 
of  the  part,  whereby  the  cells,  being  im- 
perfectly nourished,  undergo  destruction. 
[A  full  and  interesting  discussion  of 
the  matter  is  to  be  found  on  page  386  of 
Flexner's  remarkable   monograph    ("The 
Pathology  of  Toxalbumin  Intoxication," 
Johns  Hopkins  Hospital  Reports,  vol.  v, 
'97).     Barker,  in  his  studies  upon  ma- 
laria, and  Schmorl,  in  puerperal  eclamp- 
sia, have  drawn  attention  to  the  exist- 
ence  of  intraeapillary   ihroziibi   in   con- 
nection   with    these    areas    of    necrosis. 
Flexner   in    his    ricin    experiments    was 
forced  to  conclude  that  there  is  no  causal 
relationship  between  the  thrombi  and  the 
necroses,  and  that  the  localized  cell-death 
is  due  to  the  intensity  of  action  of  the 
toxic  bodies  upon  the  tissue-elements  and 
not   upon   the   circulating   blood   or   its 
channels.    J.  Geoi!OE  Adami.] 

J.  George  Adami, 

Montreal. 

CLEFT  PALATE.  See  Plastic  Sur- 
gery. 

CLITOKITIS.  —  Latin,  from  Greek, 
xlEiropigeiv,  to  titillate;  and  itis,  in- 
flammation. 

Definition. — The  question  as  to  the 
freq\iency  of  this  condition  is  one  which 
involves  great  difference  of  opinion,  and 
depends  not  a  little  upon  the  definition 
which  one  gives  to  it.  If  it  is  considered 
as  an  inflammation  which  involves  the 
structiires,  as  a  whole,  of  which  the  organ 
is  composed,  it  is,  indeed,  of  rare  occur- 
rence; but  if  we  include  that  adventi- 
tious form  of  inflammation,  often  of 
slight  intensity,  indicated  by  fibrous 
structures  which   are   attached   to   and 

2- 


bind  down  its  terminal  portion,  it  is  of 
great  frequency.  If  all  female  children 
were  carefully  examined  to  determine 
its  presence  or  absence  it  would  doubt- 
less be  recognized  much  more  frequently 
than  it  is.  It  would  probably  be  found 
as  often  as  the  analogous  condition  which 
afl'ects  the  penis  of  male  children. 

Symptoms. — The  venereal  variety  of 
clitoritis  may  be  associated  with  either 
of  the  forms  of  venereal  infection;  that 
is,  with  chancre,  chancroid,  or  gonor- 
rhoea. True  chancre  of  the  clitoris  is  of 
rare  occurrence.  In  a  dispensary  experi- 
ence of  many  years  among  women  with 
every  shade  of  venereal  disease  I  do  not 
recall  a  single  instance. 

Dr.  E.  AV.  Taylor  has  informed  me 
that  he  has  seen  it  several  times,  and  that 
it  was  characterized  by  great  pain,  swell- 
ing, and  induration,  and  reported  a  typ- 
ical case  in  a  woman,  21  years  of  age,  who 
contracted  syphilis  from  her  husband. 
The  clitoris  and  prepuce  were  indurated, 
enlarged,  and  very  painful,  and  there 
v/as  an  ulcer  at  the  tip  of  the  glans. 
Local  treatment  with  solution  of  caustic 
potash  and  lead-and-opium  lotion  pro- 
duced relief.  Other  cases  have  been  re- 
ported by  Mauriac. 

Chancroid  of  the  clitoris  I  have  seen 
several  times,  though  Taylor  thinks  it  is 
of  rare  occurrence.  Its  phenomena  are 
those  of  chancroid  on  other  portions  of 
the  female  genitalia,  viz.:  local  sore  with- 
out great  attendant  hyperajmia  in  the 
structures  of  the  clitoris,  and  usually  en- 
largement of  the  neighboring  inguinal 
glands. 

Gonorrha?a  involving  the  clitoris  is  not 
of  infrequent  occurrence.  The  phenom- 
ena are  redness  and  swelling  of  the  pre- 
puce and  to  a  greater  or  less  degree  of 
the  organ  itself:  the  accompanying  pain 
may  be  considerable.  Traumatic  clito- 
ritis is  relatively  of  rare  occurrence.  It 
16 


242 


CLITORITIS.     ETIOLOGY  AND  PATHOLOGY. 


is  the  result  of  direct  injury  from  violent 
coitus,  from  a  blow,  a  thrust,  or  a  fall, 
the  clitoris  sharing  injurj'  with  the  sur- 
rounding structxires.  The  inflammation 
follows  the  course  of  .inflammations  of  a 
traumatic  character  in  similar  vascular 
tissues,  pain  and  swelling  being  the  most 
prominent  features. 

Etiology  and  Pathology. — It  is  some- 
what surprising  that  inflammatory  phe- 
nomena of  a  decided  character  are  not 
more  frequently  connected  with  the  clit- 
oris when  we  remember  its  exquisite 
sensitiveness,  its  abundant  blood-supply, 
and  its  constant  exposure  to  irritation 
during  the  entire  period  of  life  in  which 
the  tissues  of  the  genital  organs  are  in 
an  active  functional  condition.  During 
childhood  its  conspicuous  position  in- 
vites the  injuries  to  which  childhood  is 
unusually  susceptible,  and  it  is  also  in 
danger  from  uncleanliness,  from  para- 
sites, and  from  masturbation.  After  the 
external  genitals  have  acquired  complete 
development  and  the  mature  condition 
which  follows  puberty  has  placed  the 
organ  in  a  less  exposed  situation  there 
is  still  danger  from  traumatism,  though 
not  to  a  great  degree;  from  uncleanli- 
ness, from  masturbation,  from  violence 
in  coitus,  and  from  the  poisonous  influ- 
ence of  venereal  disease.  It  would  seem 
that  the  susceptibility  to  injury  increased 
with  the  size  of  the  organ,  a  large  organ 
being  an  anomaly  and  requiring  constant 
care  and  precaution.  This  fact  empha- 
sizes the  necessity  that  the  family  physi- 
cian be  acquainted  with  the  peculiarities 
of  his  patients  in  order  to  safeguard  tliem 
from  evils  which  may  be  avoided. 

The  clitoris  may  be  the  seat  of  cystic 
disease  from  haemorrhage  or  other  cause 
(Peckham),  of  syphilitic  new  growth 
(Kelley),  of  carcinoma,  and  loss  fre- 
quently of  sarcoma  (Robb),  of  hyper- 
trophy, in  addition  to  various  congenital 


deformities  and  defects.  Its  appearance 
in  spurious  hermaphrodism  is  a  very 
good  illustration  both  of  hypertrophy 
and  of  congenital  deformity.  These 
statements  are  made  incidentally,  since  a 
true  inflammation  may  be  associated  with 
either  of  these  conditions,  a  true  clitoritis 
being  then  present. 

Inflammatory  disease  of  the  clitoris 
may,  therefore,  be  prenatal  or  postnatal 
in  its  origin,  congenital  or  acquired.  In 
the  great  majority  of  cases  it  is  prenatal; 
that  is,  it  originates  during  foetal  life. 
Why  such  a  condition  should  arise  so 
frequently  during  this  period  is  not 
known;  but  the  fact  remains  that  many 
female  children  come  into  the  world  with 
the  glans  clitoridis  surrounded  by  more 
or  fewer  bands  of  adhesion,  binding  it 
down,  interfering  with  its  circulation  and 
development,  and  furnishing  cause  for 
more  or  less  subsequent  irritation  and 
disturbance. 

Of  the  postnatal,  or  acquired,  form  of 
the  disease,  while  there  are  occasional 
instances  in  which  it  is  caused  by  un- 
cleanly habits,  by  parasites,  and  by  the 
extension  of  dermatitis  aifecting  the  con- 
tiguous tissue,  in  the  greater  number  of 
cases  it  will  be  due  to  venereal  infec- 
tion or  to  traumatism. 

With  reference  to  its  etiology,  there- 
fore, the  disease  may  be  classified  as  (1) 
congenital,  (2)  venereal,  and  (3)  trau- 
matic. 

Of  the  causes  of  the  congenital  variety 
we  are  ignorant,  as  has  already  been  re- 
marked. 

The  bands  and  strands  of  fibrous  tis- 
sue of  greater  or  less  density  and  firm- 
ness, which  are  its  visible  consequence, 
attach  its  glans  to  its  prepuce,  or  hood, 
which  is  formed  by  the  coalescence  of 
tlie  nymphas,  and  to  the  surface  which 
lies  immediately  around  it.  The  contrac- 
tion of  this  tissue,  according  to  its  abun- 


CLITORITIS. 


COCA  AND  COCAINE. 


243 


(lance  and  firmness,  interferes  with  the 
development  of  the  organ,  produces  irri- 
tation, and  probably  leads,  in  not  a  few 
instances,  to  the  habit  of  masturbation. 
It  is  conceivable,  as  Baker  Brown  in- 
sisted, that  certain  forms  of  nervous  dis- 
ease might  result  in  consequence  of  such 
conditions,  but  the  number  of  cases  in 
which  such  a  relationship  has  been  care- 
fully observed  must  be  quite  small.  In 
the  great  majority  of  cases  it  is  believed 
that  the  resulting  disturbance  has  been 
too  slight  to  require  attention  and  treat- 
ment from  the  gynascologist. 

Treatment. — There  is  little  to  be  said 
concerning  the  treatment  of  clitoritis  of 
whatever  variety. 

Best  in  bed  is  essential;  local  cleanli- 
ness equally  so.  In  the  congenital  va- 
riety the  adhesions  must  be  removed,  and 
this  can  usually  be  done  by  retracting 
the  prepuce  with  the  thumb  and  fore- 
finger of  one  hand  while  the  forefinger 
of  the  other  is  rubbed  over  the  glans  ■ndth 
sufficient  firmness  to  remove  all  obstruc- 
tions. The  bruised  surface  may  then  be 
■dusted  with  iodoform,  aristol,  or  no- 
sophen,  and  this  process  repeated  daily 
as  long  as  the  surface  remains  broken. 
For  the  venereal  variety  a  10-  or  20-per- 
ccnt.  solution  of  nitrate  of  silver  should 
be  applied  daily  upon  absorbent  cotton 
until  pain  and  swelling  have  subsided 
and  the  ulcerated  surface  has  healed. 
For  the  traumatic  variety  only  soothing 
lotions  will  be  required.  Load-and-opium 
wash,  frequently  applied  upon  absorbent 
cotton,  will  serve  the  purpose  sufficiently 
well. 

Andrew  F.  Currier, 

New  York. 

CLUB-FOOT.    See  Orthopedic  Sur- 

r.KRV. 

CITJB-HAND.  See  Orthopjedio  Sur- 
gery. 


COCA  AND  COCAINE. 

Erythro.xylon  coca  is  a  small  tree  that 
grows  wild  in  Peru,  Bolivia,  Brazil,  and 
Ecuador.  The  leaf,  which  contains  the 
active  principles,  is  the  part  used  in 
medicine.  Three  alkaloids,  hygrine, 
ecgonine,  and  cocaine  have  been  isolated 
from  the  cocoa-leaves.  Cocaine,  the  only 
one  that  has  been  found  useful  in  medi- 
cine, occurs  in  colorless,  transparent 
crystals,  which  are  soluble  in  alcohol, 
ether,  chloroform,  and  fats.  Cocaine 
forms  salts  with  the  acids,  the  hydro- 
chlorate  being  official  and  the  one  usually 
used.  The  salts  cannot  be  used  for  mak- 
ing ointments,  as  they  are  soluble  in  fats. 
Preparation  and  Dose. — Coca  (leaves), 
V2  to  1  drachm. 

Extractum    cocoe    fluidum,    ^/„    to    2 
drachms. 

Cocaine  carbolate,  ^/^  to  Ve  grain. 
Cocaine  hydrochloras,  '^/ ^  to  2  grains. 
Coca  is  best  administered  either  as  a 
tonic  or  coca,  such  as  vin  Mariani,  or  in 
the  form  of  the  fluid  extract.  When  ad- 
ministering coca  or  cocaine  the  pos- 
sibility of  intolerance  on  the  part  of  the 
patient  should  be  borne  in  mind  and  the 
danger  of  inducing  the  cocaine  habit  re- 
membered. Solutions  of  cocaine  hydro- 
chlorate  are  bitter,  and  provoke  transient 
insensibility  of  the  tongue.  Aqueous 
solutions  do  not  keep  well,  but  decom- 
pose in  a  short  time  and  lose  their  effi- 
ciency. 

Series  of  experiments  indicating  (1) 
that  cliloral-liydrate  is  a  decided  antag- 
onist of  cocaine,  being  able  to  counter- 
act tlie  action  of  doublylotlml  doses 
given  to  a  dog;  (2)  other  hypnotics, 
such  as  paraldehyde,  are  likewise  an- 
tagonistic to  cocaine:  (3)  the  antag- 
onism is  complete,  influencing  all  the 
important  organic  functions;  (4)  it  is 
a  onesided  antagonism,  for  cocaine  does 
not  counteract  poisoning  by  the  hyp- 
notics; (.5)  the  antagonism  is  a  meehan- 
ieal  one,  similar  to  the  antagonism  be- 


244 


COCA  AXD  COCAIXE.    PHYSIOLOGICAL  ACTIOX.    POISONING. 


tween  the  hypnotics  and  strychnine. 
Carlo  Gioffredi  (Giornale  Inter,  delle 
Scienze  lied.,  Aug.  31,  1900). 

Physiolo^cal  Action. — When  taken 
internally,  coca  and  its  alkaloid  produce 
a  sensation  of  exhilaration  and  pleasure 
similar  to  that  produced  by  a  large  dose 
of  caffeine.  There  is  a  marked  tendency 
to  wakefulness,  a  feeling  of  increased 
mental  and  muscular  strength  and  vigor, 
and  an  absence  of  hunger.  The  brain  is 
stimulated,  but  the  sensory  nerves  are 
not  generally  affected,  and,  if  at  all,  the 
effect  is  very  feeble  and  is  due  to  an 
influence  on  the  spinal  cord  (Mosso). 
When  applied  locally  to  the  sensory 
nerves  cocaine  paralyzes  them.  This 
also  happens  if  the  internal  dose  be  very 
large.  The  effect  upon  the  muscles  when 
taken  internally  is  direct  stimulation, 
most  marked  after  fatigue. 

Maurel,  of  Toulouse,  has  shown  that 
under  the  influence  of  cocaine  the  leuco- 
cytes undergo  changes;  they  become 
spherical  and  rigid,  increase  in  size,  and 
no  longer  adhere  to  the  vessel-walls.  On 
the  other  hand,  the  capillaries  contract, 
and  thrombosis  and  embolism— particu- 
larly pulmonary  embolism — may  be  pro- 
duced. 

Upon  the  heart  and  circulation  co- 
caine in  moderate  amounts  acts  as  a 
stimulant,  the  heart-beats  being  in- 
creased in  number  and  force;  but  marked 
effects  only  follow  a  poisonous  dose. 
Cocaine  is  a  respiratory  stimulant,  large 
doses  increasing  the  number  of  respira- 
tions; in  poisonous  doses  it  kills  by  fail- 
ure of  respiration  associated  with  exhaus- 
tion from  the  accompanying  convulsions 
(Hare).  Cocaine  increases  body-heat  to 
a  marked  degree  if  given  in  overdose, 
this  rise  being  due  to  increase  of  heat- 
production  (Reichert).  When  applied 
locally  to  mucous  membranes,  cocaine 
produces   an   anesthetic   effect,   accom- 


panied with  a  blanching  of  the  mem- 
brane, followed  by  a  marked  congestion. 
When  injected  beneath  the  skin  cocaine 
produces  a  local-ansBsthetic  effect.  Ap- 
plied externally  to  the  skin  it  produces 
little  effect. 

The  rise  of  temperature  caused  by 
cocaine  is  due  to  an  increase  of  heat- 
production,  and  the  latter  depends  upon 
two  actions:  one,  of  the  cortex,  causing 
motor  excitement,  and  the  other,  upon 
the  caudate  thermogenic  centre,  by 
which  heat  is  produced  independently  of 
motor  activity.  Cocaine  possesses  very 
little  power  as  a  thermogenic  in  ani- 
mals lightly  curarized,  because  of  both 
the  motor  quietude  and  the  depression 
of  some  other  portion  of  the  thermo- 
genic apparatus.  It  is  absolutely  with- 
out thermogenic  power  in  animals  in 
which  the  pathways  of  thermogenic  and 
cortico-spinal  motor  fibres  have  been 
cut,  as  after  section  of  the  spinal  cord 
at  its  junction  with  the  bulb  and  of 
crura  cerebri.  Cocaine  is  effective  as  a 
thermogenic  when  only  a  small  portion 
of  the  caudate  centre  is  left  intact  with 
the  parts  below.  Cocaine  and  morphine 
are  direct  antagonists  in  their  actions 
upon  the  caudate  and  cortical  centres 
which  are  directly  or  indirectly  involved 
in  the  changes  of  temperature  and  heat- 
production.  E.  T.  Eeichert  (Pliila.  Mod. 
.Tmir.,  Aug.  2,  1902). 

Poisoning  by  Cocaine.  —  Acute 
PoTSONiNG. — When  cocaine  is  given 
in  poisonous  doses  the  symptoms  no- 
ticed are  an  exaggerated  sense  of  mental 
and  physical  well-being,  loquacity  and 
mental  incolierence,  profuse  diaphoresis, 
fall  of  temperature;  shallow,  irregular 
breathing;  dilated  pupils,  disturbed 
vision,  nausea,  feeble  pulse,  and  finally 
collapse. 

Epileptiform  convulsions  have  also 
been  noted  with  disordered  circulation 
and  respiration;  the  convulsions,  both 
tonic  and  clonic  in  type,  are  of  cerebral 
origin. 

SmallcRt  hypodermic  dose  observed  to 
produce  faintncss   and   nausea   was  '/m 


COCA  AND  COCAINE.    POISONING.    TREATMENT.    THERAPEUTICS. 


245 


grain:  in  tlie  case  of  a  man  aged  65. 
Old  people  are  especially  susceptible,  and 
it  is  advisable  in  every  case  to  have 
brandy  and  amyl-nitrite  at  hand.  J. 
Jackson  Clarke  (Lancet,  Jan.  18,  '96). 

Case  of  acute  cocaine  poisoning,  an 
injection  of  '/,  grain  of  the  drug  for 
relief  of  severe  pain  being  given.  Within 
five  minutes  the  pain  had  all  disap- 
peared. The  next  day  V:  grain  only  was 
injected ;  within  three  minutes  there  was 
a  faint  feeling,  with  collapse,  followed 
by  rapid  heart-action  and  respiration; 
after  ten  minutes  clonic  contractions 
with  widened  pupil,  bulging  globes,  and 
other  severe  symptoms.  These  passed 
off,  and  by  the  ne.xt  day  the  man  was 
out.  The  pain,  which  had  been  of  long 
standing  in  the  region  of  the  hip-joint, 
did  not  return.  Bergmann  (MUnehener 
med.  Woch.,  Mar.  20,  1900). 

Instance  of  the  toxicity  of  cocaine.  A 
strong  man,  aged  46,  was  seized  with 
severe  epistaxis,  which  recurred  in  spite 
of  treatment.  The  bleeding  came  from  a 
spot  in  the  floor  of  the  left  nostril.  Two 
applications  of  a  10-per-cent.  solution  of 
cocaine  were  made  to  this,  resulting  in 
an  alarming  attack  of  an  epileptiform 
nature,  the  clonic  spasms  continuing  for 
nearly  ten  minutes.  The  epistaxis  ceased 
during  the  convulsions,  and  did  not  re- 
cur.    Kohn  (Med.  Record,  Mar.  24,  1900). 

Case  under  treatment  for  the  mor- 
phine habit,  who  was  known  to  be  very 
susceptible  to  cocaine,  received  by  the 
mouth,  30  milligrammes  (nearly  Vi 
grain)  of  that  substance.  The  pulse, 
which  was  normally  weak  and  never 
faster  than  SO,  rose  to  104  and  became 
hard  and  tense.  A  noticeable  feature 
was  the  enlargement  of  the  outline  of 
the  heart,  with  marked  palpitation, 
which  occasioned  much  alarm  to  the 
patient.  The  case  terminated  in  recov- 
ery. J.  Hofraann  (Therap.  Monats.,  No. 
11,  1901). 

Thus  we  liave  two  phases  of  acute 
poisoning;  one  with  symptoms  of  de- 
pression, the  other  convulsive  in  type. 

CnuoNic  Poisoning.  —  Chronic 
poisoning  by  cocaine,,  or  the  "cocaine 
habit,"   occurs  sometimes  alone,   some- 


times associated  with  the  opium  habit. 
The  symptoms  after  cocaine  habit  con- 
sist of  marked  loss  of  body-weight,  dis- 
ordered circulation,  loss  of  mental  power 
and  moral  perception,  and  delusion,  sim- 
ilar to  those  affecting  the  subjects  of 
chronic    alcoholism.      (See    Cocaino- 

MANIA.) 

Treatment  of  Cocaine  Poisoning.  — 
The  treatment  of  acute  poisoning  where 
the  symptoms  are  those  of  depression 
consists  in  the  exhibition  of  sal  vola- 
tile, coffee,  strychnine,  caffeine,  digitalis, 
ether,  and  alcohol.  If  the  symptoms  are 
of  the  convulsive  type,  the  treatment 
should  be  the  same  as  that  of  strychnine 
poisoning:  inhalations  of  amyl-nitrite, 
bromides  with  chloral;  if  convulsions 
prevent  swallowing,  use  chloroform 
ansesthesia  and  give  antidotes  by  rectum 
in  starch-water.  Amyl-nitrite  and  mor- 
phine by  hypodermic  injection  are  indi- 
cated if  relaxation  does  not  occur. 

From  experiments  upon  animals  in  re- 
gard to  lavage  of  organism  in  acute  co- 
caine poisoning,  the  following  deductions 
made;  — 

1.  While  the  minimum  fatal  dose  of 
cocaine  muriate  administered  hypoder- 
mically  is  0.025  gramme  per  kilogramme, 
one  can  inject,  of  the  same  drug,  with- 
out fatal  result:  (n)  gramme  0.03,  if  we 
follow  the  said  injection  with  hypo- 
dermoclysis;  (6)  and  0.035  gr.  per  kilo- 
gramme if  we  follow  the  said  injection 
with  lavage  of  the  organism  by  the  in- 
jection of  the  physiological  solution  of 
sodium  chloride. 

2.  \Miile  the  minimum  fatal  dose  of 
cocaine  muriate  administered  fasting  by 
the  alimentary  canal  is  3 '/»  centi- 
grammes per  kilogramme,  one  can,  with 
lavage  of  the  organism,  administer  as 
much  as  5  Vi  centigrammes  per  kilo- 
gramme without  fatal  results.  Carlo 
Bozza  (Gior.  Internaz.  delle  Sci.  Med., 
Feb.,  '98). 

Therapeutics.  —  The  therapeutics  of 
this  drug  may  be  conveniently  treated 
under  three  heads:  the  internal,  hj-po- 


246 


COCA  AND  COCAINE.     INTERNAL  ADMINISTRATION. 


dermic,  and  topical  administrations. 
Coca  and  cocaine  are  contra-indicated  in 
fatty  heart,  arterial  atheroma,  pernicious 
ansmia,  hysteria,  and  epilepsy. 

The  first  and  greatest  precaution  to  be 
taken  before  the -hypodermic  injection  is 
the  preliminary  physical  examination; 
this  should  be  made  with  the  utmost 
thoroughness;  if  the  patient  is  suffering 
with  organic  disease  of  the  brain,  heart, 
lungs,  or  kidneys,  or  any  confirmed 
neurotic  disorder,  injection  of  the  drug 
must  not  be  attempted.  The  patient 
should  be  placed  in  a  recumbent  posi- 
tion, with  the  head  low,  and  he  should 
not  be  allowed  to  rise  for  at  least  fifteen 
minutes  after  the  cocaine  has  entered 
the  general  circulation.  Where  it  is 
possible  to  use  constriction,  it  should 
never  be  omitted.  After  the  operation, 
tourniquet  is  loosened  and  immediately 
tightened.  This  is  repeated  at  intervals 
of  a  few  minutes  until  the  cocaine  has 
probably  all  entered  the  circulation. 
C.  A.  Dunmore  {Codex  Medicus,  Dec, 
'95). 

Cocaine     administration     in     medical 
practice  can  be  rendered  absolutely  safe 
by  refusing  its  use  in  persons  with  kid- 
ney and  heart  affections,   and   tlie   em- 
ployment  of   means   which   will   fortify 
against  the  possible  occurrence  of  acci- 
dents.   Accidents  can  be  avoided  by  the 
administration    of    morphine    and    atro- 
pine.    O.xygen-gas  is  the  only  true  anti- 
dote.    Charles  Wilson  Ingraham    (Med. 
News,  Jan.  22,  '9G). 
Internal  Administration. — For  inter- 
nal administration  the  fluid  extract  of 
coca  or  a  good  coca-wine,  such  as  vin 
Mariani,  is  preferred.     The  elixir  and 
tincture  are  not  sufficiently  active  or  re- 
liable. 

Cocaine   successfully   used   in   several 
cases  of  seasickness.     A  cathartic  was 
first  administered,  then  5  minims  of  a 
4-per-cent.  solution   of  cocaine  repeated 
every  hour  or  two  until  three  doses  were 
taken.     A.  D.   Rockwell    (Med.   Record, 
Apr.  1,  '90). 
Fevkii. — The    stimulating    and    sup- 
porting effects  of  coca  are  well  known 
and  may  be  utilized  in  all  forms  of  low 


fever.  In  yellow  fever  it  is  of  especial 
value  on  account  of  its  anti-emetic  prop- 
erty. 

Vomiting  of  Pkegnanct. — Coca  has 
been  found  useful  in  many  cases  of  this 
distressing  malady  and  in  other  forms  of 
vomiting.  From  Vs  to  1  wineglassful  of 
vin  Mariani  or  1  to  2  tablespoonfuls  of 
the  fluid  extract  may  be  taken  three  or 
four  times  daily,  preferably  after  meals, 
so  as  not  to  impair  the  appetite. 

Fatigue. — In  persons  suffering  from 
fatigue,  coca  is  found  to  rest  and  freshen 
the  mental  and  physical  powers,  giving 
a  feeling  of  comfort  and  well-being,  and 
making  possible  the  endurance  of  fur- 
ther work  and  strain.  To  those  who  are 
about  to  undergo  unusual  strain  or 
fatigue,  coca  acts  as  a  powerful  stimu- 
lant. Overindulgence  in  this  use  of  coca 
is  strongly  advised  against,  in  view  of  the 
danger  of  forming  the  habit. 

Opium  Habit.- — Coca  has  been  em- 
ployed as  a  stimulant  during  the  with- 
drawal of  the  opium,  but  its  use  is  not 
without  the  danger  that  the  one  habit 
may  be  replaced  by  the  other,  or,  indeed, 
become  associated  with  it. 

Pyloric  Carcinoma. — Cocaine  car- 
bolate  has  been  used  with  success  in  these 
and  other  cases  where  a  combination  of 
an  anaesthetic  and  antiseptic  was  desired. 
The  dose  used  was  V12  to  Vo  grain  in 
wine  or  diluted. 

Nervous  Disorders.  —  In  melan- 
cholia and  neurasthenia  coca  has  been 
used  with  advantage,  especially  when  as- 
sociated with  a  moderately-anaemic  con- 
dition, a  feeling  of  depression,  loss  of 
appetite,  and  impaired  digestion,  other 
appropriate  remedies  being  associated 
with  it.  A  wineglassful  of  coca-wine 
every  three  hours  usually  brings  about  a 
Ijcneficiiil  elmnge  in  a  day  or  two. 

Hypodermic  Administration. — |i'or  hy- 
podermic use  the  salts  of  cocaine  are  used 


COCA  AND  COCAINE.    LOCAL  AN/ESTHESLA. 


247 


(generally    the    hydrochloratc),    as    the 
alkaloid  requires  1300  parts  of  water  for 
its  solution.    A  4-  to  S-per-cent.  solution 
is  generally  employed,  and  not  more  than 
V<  grain  of  cocaine  should  be  injected. 
Solution  employed  by  writer  contains 
10  per  cent,  of  resorcin  and  20  per  cent, 
of   the   hydrochlorate    of   cocaine.     The 
addition  of  resorcin  diminishes  tlie  toxic 
effect  of  cocaine,  while  at  the  same  time 
it  increases  the  ancesthetic  effect  of  the 
latter,    and    it    moreover    prevents    the 
cocaine    crystallizing    out.      The    anti- 
septic properties  of  resorcin  in  the  solu- 
tion are  also  of  value.    Use  of  the  spray 
for   applying   cocaine   to    the    nose   dis- 
approved of.     If  after  the  application  of 
a  solution  of  cocaine  the  patient  becomes 
pale,  giddy,  or  faint,   1   drachm   of  the 
aromatic  spirit  of  ammonia,  in  2  ounces 
of  water,  should  be  given,  and  the  pa- 
tient    directed     to     sip     the     draught. 
E.  de  H.  Hall    (Brit.   Med.   Jour.,  Feb. 
8,  '90). 

Extra  care  should  be  observed  and  a 
smaller  dose  given  where  injections  are 
made  about  the  head,  face,  and  neck. 
The  hypodermic  use  of  cocaine  is  em- 
ployed to  relieve  pain,  and  to  induce 
local  anaesthesia  for  the  purpose  of  mak- 
ing some  surgical  operation. 

Neuralgia.  —  Sciatica,  pleurodynia, 
etc.,  and  all  forms  of  muscular  rheuma- 
tism are  best  treated  by  hypodermic  in- 
jection. For  all,  except  neuralgia  of  the 
head  and  face,  ^/ ^  to  '/„  grain  should  be 
injected  over  the  seat  of  the  pain;  for 
the  two  latter,  the  injection  should  be 
made  into  the  arm. 

The  result  is  marked  in  nearly  all 
cases.  The  pain  disappears  almost  en- 
tirely for  several  hours,  when,  if  it  re- 
turn, it  is  in  a  milder  form.  Injections 
should  be  continued  as  long  as  the  pain 
lasts. 

Cocaine  anaesthesia  is  contra-indicated 
in  all  irregular  and  all  great  operations, 
as  well  as  in  abdominal  surgery.  Its 
principal    use    is   in    weakened   subjects 


afl'ected  by  organic  taints  or  otherwise. 
The  cocaine  should  not  be  allowed  to 
enter  the  general  circulation. 

Local  Anassthesia. — Several  methods 
of  producing  local  anaesthesia  by  the  hy- 
podermic use  of  cocaine  have  been  sug- 
gested other  than  the  simple  one  em- 
ployed in  medication  with  other  remedies. 

The  painless  method  is  one  in  which, 
after  the  part  to  be  injected  has  been  sub- 
jected to  antiseptic  cleansing,  the  part  is 
sprayed  with  rhigolene  or  ethyl-chloride 
until  insensibility  to  pain  is  induced. 
The  point  of  the  needle  is  introduced 
just  below  the  epidermis  and  a  drop 
or  two  injected  into  the  tissues.  This 
produces  an  area  of  insensibility  within 
the  edges  of  which  other  injections  are 
made,  gradually  increasing  the  extent  of 
the  area  of  insensibility.  Coming,  who 
suggests  this  method,  advises  the  injec- 
tion of  the  subepidermal  region  first,  and 
subsequently  the  deeper  tissues. 

The  endermic  method  consists  in  first 
producing  a  small  blister,  withdrawing 
the  serum  therefrom  with  a  syringe,  and 
replacing  it  with  a  solution  of  cocaine. 
This  method  has  no  practical  value  in 
surgery. 

Prolongation  of  Local  Action  of 
Cocaine  for  Surgical  PuRrosE. — By 
arresting  the  arterial  and  venous  circu- 
lation. Corning  has  demonstrated  that 
when  cocaine  is  injected  into  an  ex- 
tremity its  action  may  be  prolonged  for 
ninety  minutes,  if  necessary.  This  arrest 
he  accomplishes  by  the  aid  of  appropriate 
ligature  about  the  limb,  or  in  the  case 
of  the  breast  or  back  by  the  application 
of  rings,  clamps,  etc.  He  maps  out  the 
veins  (to  avoid  puncture)  by  tying  a 
piece  of  elastic  webbing  above  the  field 
of  operation.  As  the  veins  become 
swelled  he  traces  their  course  with  a  col- 
ored pencil  and  then  removes  the  web- 
bing.    The  limb  is  next  exsanguinated 


248 


COCA  AND  COCAINE.     LOCAL  AN.LSTHESLi. 


with  an  ordinary  Esmarcli  bandage  car- 
ried up  to  (but  not  beyond)  the  field  of 
operation  and  maintained  in  phice  till 
the  injections  of  the  anaesthetic  are  com- 
pleted. A  strong  flat  tourniquet  is  then 
applied  about  the  limb  alove  the  field  of 
operation  and  dra'mi  tight  enough  to  in- 
terrupt the  circulation  in  the  vessels. 
The  Esmarch  bandage  is  then  removed, 
and  the  field  is  ready  for  operation. 

:  Case   in   which   Esmarch's   constrictor 

was  applied  immediately  above  the  mal- 
leoli; a  solution  of  cocaine  (1  per  cent.) 
was  then  injected  in  the  position  of  the 
different  nerve-tninks,  a  number  of  dif- 
ferent punctures  being  made  with  the 
needle.      After    an    inten-al    of    three- 

;  fourths  of  an  hour,  the  operation  took 

place;  this  consisted  in  the  removal  of 
the  great  toe,  its  metatarsal  bone,  and 
of  the  cuneiforms,  in  addition  to  scrap- 
ing with  the  sharp  spoon  and  stitching 
of  the  skin.  During  the  hour  employed 
in  these  procedures,  the  patient  was 
quite  unaware  of  their  progress.  It  is 
essential,  in  all  cases  in  which  it  is  de- 
sired to  completely  ansEsthetize  the  hand 
or  foot,  that  the  rubber  tourniquet  be 
very  firmly  applied,  and  that  a  sufficient 
interval  (not  less  than  twenty  minutes) 
be  allowed  to  elapse  between  the  injec- 
tion of  the  cocaine  and  the  operation. 
Otto  Manz  (Centralb.  f.  Chir.,  Feb.  19, 
'98). 

Case  in  which  an  abdominal  section 
was  performed  under  cocaine  ansesthesia 
for  retroverted  adherent  uterus,  owing  to 
marked  cardiac  symptoms  and  goitre. 
Eight  minims  of  .5-per-cent.  solution  of 
cocaine  having  been  injected  beneath  the 
Bkin,  an  incision  was  made  in  the  median 
line  down  to  the  muscle-sheath.  Eight 
minims  more  were  injected  at  dilTcrent 
points  along  the  median  line  into  the 
muscular  structures,  and  the  incision  was 
tlien  carried  into  the  peritoneal  cavity. 
The  adhesions  binding  the  uterus  down 
to  the  rectum  were  then  separated  with- 
out any  apjjarcnt  discomfort  to  the  [la- 
ticnt.  I5ut  even  slight  traction  upon  I  lie 
ovaries  Hceiiied  to  produce  considerable 
pain.     The  uterus  was  brought  forward 


and  stitched  according  to  the  ordinary 
suspension  method.  The  peritoneum  was 
closed  by  means  of  a  continuous  catgut 
suture.  The  patient  made  an  uninter- 
rupted convalescence.  Hunter  Robb 
(Cleveland  Med.  Gaz.,  Feb.,  '99). 

Amputation  under  cocaine  anresthesia 
in  a  case  of  gangrene  of  the  foot,  the 
patient  being  too  weak  to  take  a  general 
anaesthetic.  Tlie  limb  was  encircled  with 
a  broad  elastic  band,  and  two  injections 
of  cocaine  solution  made  in  the  region 
of  the  main  nerve-trunks.  After  waiting 
thirty  minutes  amputation  at  the  knee 
was  carried  out  almost  painlessly. 
Berndt  (Munchener  med.  Woch.,  July 
4,  '99). 

Case  of  poisoning  in  which  the 
amount  of  cocaine  hydrochlorate  used 
during  the  operation  was,  roughly 
speaking,  between  0.16  and  0.19  gramme 
(2V:  and  3  grains),  enough  to  cause 
the  most  serious  outcome.  The  fault 
lay  in  the  continued  use  of  the  strong 
solution  without  resorting  to  further 
infiltration  dilution  by  means  of  the 
weak  soda  solution,  and  upon  too  groat 
reliance  of  leakage  during  the  course  of 
the  dissection. 

Both  chloral  and  opium  in  the  form 
of  morphine  sulphate  have  been  sug- 
gested as  natural  antidotes  in  cases  of 
cocaine  poisoning.  In  several  unre- 
corded instances  in  the  surgical  work 
of  other  operators  the  writer  has  seen 
the  prompt  eff'eet  produced  by  mor- 
phine. Frederic  Griffith  (Anier.  Med., 
March  7,  1903). 

Therapkutic  Thrombosis. — This  is 
a  method  also  devised  by  Corning  for  the 
localization  and  prolongation  of  the 
action  of  cocaine.  Four  principles  are 
embodied  in  the  procedure: — 

1.  Injection  of  the  anaesthetic  (co- 
caine) into  the  skin. 

2.  The  subsequent  introduction 
through  the  same  hypodermic  needle, 
and  without  its  removal  from  the  part, 
of  a  non-irritant  oil  (cocoa-butter). 

3.  Trccipitation  of  this  oil,  after  its 
injfclioR   inio   iJic  skin,  by  the  aid   of 


COCA  AND  COCAINE.    LOCAL  ANAESTHESIA. 


249 


moderate  cold,  but  without  freezing  the 
tissues. 

4.  Taking  up  the  slack  of  the  skin  near 
the  seat  of  the  injection,  should  the  in- 
tegument be  very  elastic.  By  the  appli- 
cation of  these  principles  he  has  suc- 
ceeded in  maintaining  a  limited  zone  of 
anaesthesia  for  considerably  over  an  hour. 

Infiltration  ANiESTHESiA.  —  This 
method  of  local  anesthesia  was  devised 
by  Schleich,  of  Berlin,  and  employed  by 
him  in  all  kinds  of  operations,  including 
laparotomy.  He  uses  a  weak  solution  of 
cocaine  (1  to  1000),  the  solvent  being  a 
saline  solution  (of  0.2-  to  0.3-per-cent. 
sodium  chloride).  A  small  spot  on  the 
skin  near  the  field  of  operation  is  sprayed 
with  ethyl-chloride,  and  when  insensible 
to  pain  is  injected  with  a  few  drops  of  the 
cocaine  solution.  At  the  spot  of  infiltra- 
tion a  wheal  immediately  arises,  which 
is  absolutely  without  sensation.  Pushing 
the  point  of  the  syringe  farther  under 
the  skin  through  this  area  of  insensibil- 
ity a  few  drops  are  again  injected. 

Another  wheal  rises  close  to  the  first, 
and  by  extending  these  injections  far- 
ther and  farther  round  the  field  of  opera- 
tion, the  whole  is  infiltrated  and  ren- 
dered anassthetic.  The  injection  must 
always  be  made  into  healthy  skin,  other- 
wise a  slough  is  likely  to  follow.  The 
formula  generally  used  is  as  follows: 
Cocaine  hydrochlorate,  2  grains;  steril- 
ized distilled  water,  4  fluidounces;  sol. 
carbolic  acid  (5  per  cent.),  3  drops. 

The  corium  should  be  first  filled  with 
the  solution.  This  is  accomplished  by 
using  a  very  fine  needle  and  introducing 
it  almost  parallel  to  the  surface  of  the 
skin.  A  few  drops  are  injected,  causing 
a  .slight  wheal  to  appear,  and  after  a 
pause  of  a  few  seconds  the  needle  is 
pushed  farther,  and  the  process  is  re- 
peated until  the  whole  of  the  corium  is 
infiltrated.  The  siiboutaneous  and 
deeper   tissues   are   to    be   treated    in    a 


similar  way.     J.  Jackson  Clarke    (Lan- 
cet, Jan.  18,  '90). 

Spinal  Subarachnoid  Injections. 
— This  method  of  producing  anesthesia 
was  first  resorted  to  by  J.  Leonard  Corn- 
ing, of  New  York.  It  consists  in  the  in- 
jection of  a  solution  of  cocaine  into  the 
subarachnoid  cavity.  This  soon  acts 
upon  the  spinal  centres  and  ganglia,  and 
the  whole  or  lower  half  of  the  body  be- 
comes analgesic. 

The  needle  should  be  of  gold  or  plati- 
num, from  three  inches  and  a  half  to 
four  inches  in  length,  and  the  bevel  of 
the  point  should  be  short.  It  should  be 
provided  with  a  small  steel  nut,  sliding 
freely  upon  the  needle  and  fixable  at  any 
point  of  its  length  by  a  set-screw.  When 
the  needle  is  finally  within  the  spinal 
canal,  this  nut  is  pressed  against  the  skin 
and  fixed  in  place  so  as  to  prevent  any 
further  entrance  of  the  needle.  The 
needle  is  left  in  silu  until  anesthesia 
supervenes,  and  is  then  withdrawn.  The 
most  rigid  asepsis  is  enjoined.  It  is 
preferable  to  puncture  between  the  sec- 
ond and  third  lumbar  vertebre,  as  this 
causes  the  anesthetic  to  arrive  at  the 
cord  more  quickl}',  and  in  a  more  concen- 
trated condition  than  when  introduced 
lower  down.  Coming  notes  that  there 
has  been  a  singular  immunity  from 
fatality  until  now — but  this  will  not  go 
on  indefinitely,  and  there  should  be  a 
concerted  effort  by  the  invocation  of 
every  known  precaution  to  keep  the 
mortality  as  low  as  possible. 

While,  as  stated,  the  point  of  introduc- 
tion is  a  space  between  the  fourth  and 
fifth  lumbar  vertebre,  one-half  inch 
from  the  median  line,  the  patient  occu- 
pying a  sitting  position,  in  some  cases  of 
spinal  deformity  it  has  been  impossible 
to  insert  the  needle  at  this  point.  Injec- 
tions have  been  made  between  the  sixth 
and    seventh    cervical    vertebra?.      The 


250 


COCA  AND  COCAINE.    LOCAL  AN.ESTHESL4. 


fluid  should  never  be  injected  except 
when  the  cerebro-spinal  fluid  is  flowing 
from  the  needle,  and  it  should  alwaj^s  be 
injected  slowly,  requiring  from  forty  to 
sixty  seconds. 

The  sjTnptoms  as  described  by  Mur- 
phy (Jour.  Amer.  Med.  Assoc,  Feb.  9, 
1901)  are  as  follow:  First  there  is  a  sen- 
sation of  heat  passing  over  the  entire 
body,  then  that  of  thirsty  followed  in  a 
few  minutes  by  nausea,  which  may  last 
for  ten  minutes.  Preceding  the  vomiting 
there  is  increased  rapidity  of  pulse,  pal- 
lor, and  respiration.  These  symptoms 
last  for  a  few  minutes  usually,  but  are  in 
some  cases  very  marked  and  make  stimu- 
lation necessary.  Murphy  thinks  that 
hyoscine  hydrobromate,  ^/^m  grain,  and 
nitroglycerin,  Vioo  grain,  are  the  best 
stimulants  under  the  circumstances. 
The  analgesia  usually  appears  in  from  3 
to  10  minutes,  though  sometimes  it  may 
be  delayed  from  20  to  30.  It  usually  be- 
gins in  the  feet  and  gradually  ascends, 
though  in  rare  instances  it  may  first  ap- 
pear as  a  band  around  the  body  and  then 
descend.  And  in  rarer  instances  still  it 
has  been  known  to  ascend  from  the  level 
of  the  injection  and  involve  the  upper 
extremities,  the  neck,  and  face. 

The  post-operative  symptoms  are: 
Headache,  lasting  several  hours  to  sev- 
eral days;  more  or  less  prolonged  vomit- 
ing; vertigo  and  some  ataxia  in  gait, 
which  may  persist  for  some  days;  rise  of 
temperature.  Coma  and  delirium  have 
been  observed.  Mental  exaltation  fre- 
quently so.  Failure  to  obtain  analgesia 
after  the  employment  of  this  method  ia 
ascribed  by  Murphy  to  faulty  technique 
or  personal  idiosyncrasy.  Alcoholism 
exposes  the  patient  to  be  unfavorably 
affected. 

Bier,  of  Kiel  (Deutsche  Zeitschrift 
fiir  Chirurgie,  Apr.,  '99),  first  nnfes- 
thetizes  the  region  for  the  fniiicliire  Ijy 


Schleich's  plan  of  infiltration.  He  then 
injects  within  the  meningeal  cavity  a 
few  drops  of  a  dilute  solution  of  cocaine, 
introducing  from  ^/m  to  ^/e  grain. 

Four  cases  in  which  the  method  was 
used  for  major  operations.  A  slightly 
larger  quantity  of  cocaine  was  used  than 
recommended  by  Bier  (Vo  grain  of  co- 
caine), but  the  effects  produced  were 
pi^actically  the  same,  complete  auEes- 
thesia  following  in  every  case  and  last- 
ing sufficiently  long  for  the  completion 
of  the  operations,  the  longest  of  which 
lasted  fifty  minutes.  The  operations  per- 
formed were  a  Pirogoff  amputation  of 
the  foot  for  carcinoma;  amputation  of 
the  leg  and  extirpation  of  the  inguinal 
glands  for  melanosarcoma  of  the  calca- 
neum;  removal  of  an  extensive  skin  car- 
cinoma in  the  region  of  the  knee  and  en- 
larged inguinal  glands;  and  resection  of 
the  knee  for  tuberculosis.  Sensation  re- 
turned a  short  time  after  the  completion 
of  the  operation,  and  there  were  no  seri- 
ous after-eiTects  in  any  case.  Seldowitach 
(Centralb.   f.    Qiir.,   vol.   xxvi,   p.    1110, 

The  technique  of  the  lumbar  puncture 
is  not  as  simple  as  might  be  supposed. 
In  stout  individuals  the  spinous  proc- 
esses are  difficult  of  palpation,  and  even 
in  cases  where  there  are  not  consider- 
able fat  a  patient  that  was  very  nervous 
when  placed  in  a  direct  posture  would 
throw  the  muscles  into  such  rigidity  as 
to  render  it  almost  impossible  to  fix  the 
point  of  the  spinal  process.  Unless  the 
lumen  of  the  needlfe  had  become  oc- 
cluded in  its  passage  through  the  soft 
parts,  cerebro-spinal  fluid  flows  without 
any  difficulty.  In  some  cases  aspiration 
either  with  the  syringe  that  is  being  em- 
ployed or  a  special  suction  will  still 
more  facilitate  the  outflow  of  the  cere- 
bro-spinal fluid.  It  is  well  to  allow  a 
full  minute  for  the  injection,  thus  giv- 
ing ample  time  for  the  solution  to 
thoroughly  mix  with  the  cerebro-spinal 
fluid.  The  solution  should  be  freshly 
prepared  with  a  menstruum  of  sterilized 
water  and  boiled  for  a  full  minute  be- 
fore using.  It  is  believed  that  a  con- 
centrated solution  of  a  deflnite  quantity 
will  not  produce  disagreeable  symptoms 


COCA  AND  COCAINE.     LOCAL  ANESTHESIA. 


251 


any  more  than  the  same  dose  in  a  di- 
luted solution,  and  that  the  effect  will 
last  longer.  Analgesia  is  present  in  the 
soles  of  the  feet  from  1  to  5  minutes, 
and  in  from  5  to  15  minutes  extends  to 
the  \imbilieus.  In  no  personal  case  did 
it  fail  to  reach  the  umbilicus  when  the 
solution  proved  at  all  effective;  in  2 
cases  it  reached  to  the  vertex.  In  none 
of  the  cases  did  the  analgesia  subside 
below  the  umbilicus  under  27  minutes. 
The  amount  of  cerebro-spinal  fluid  pres- 
ent in  each  case  has  probably  direct 
bearing  upon  the  extent  of  the  anal- 
gesia. With  a  reliable  solution  it  is  be- 
lieved that  a  failure  to  produce  anal- 
gesia depends  upon  the  failure  to  intro- 
duce the  solution  into  the  spinal  cord. 
In  the  greater  number  of  cases  disagree- 
able features  were  present,  among  them 
being  vertigo,  nausea,  vomiting,  head- 
ache, chills,  elevation  of  temperature 
and  increased  pulse-rate,  pallor,  cold 
sweat,  and  involuntary  urination  and 
defecation.  The  case  of  Tuffier,  in 
which  death  occurrea,  was  found,  upon 
a  post-mortem  examination,  to  have 
been  affected  with  cardiac  and  pulmo- 
nary lesions.  In  some  personal  cases 
there  were  even  heart-murmurs  present, 
and  in  one  case  there  was  gangrene  of 
the  lungs,  but  no  harm  supervened. 
Insensibility  to  the  surgical  procedure 
is  not  all  that  should  be  required  of  an 
ideal  anesthetic,  and,  on  the  other  hand, 
such  features  as  the  knowledge  by  the 
patient  of  what  is  taking  place  around 
him  and  the  perception  of  the  gravity 
of  the  operation  are  to  be  distinctly 
avoided.  A  further  trial  and  conscien- 
tious study  of  a  large  collection  of  cases 
is  still  required  to  ascertain  the  danger 
that  may  accompany  employment  of 
this  form  of  anresthesia.  G.  R.  Fowler 
(Phila.  Med.  Jour.,  from  Jled.  News, 
Jan.  5,  1901). 

In  obstetrical  and  gyntrcological  cases 
the  following  technical  points  are  im- 
portant: 1.  Surgical  cleanliness  in  all 
things  and  a  fresh,  aseptic  solution  of 
cocaine,  full  strength.  The  method  of 
sterilization  used  at  the  present  time  is 
to  raise  the  temperature  of  the  solution 
(in  small  bottles)  to  SO"  C.  for  one  hour 
on  two  successive  davs.    2.  The  needle   ' 


need  not  be  longer  than  7  centimetres 
and  sliould  be  kept  sharpened.  3.  A 
nurse  should  stand  at  patient's  head 
when  the  puncture  is  made  to  keep  the 
back  arched  forward.  A  case  was  re- 
cently reported  in  this  city  of  a  patient 
suddenly  sitting  upright  and  breaking 
the  needle.  4.  During  an  operation  the 
patient's  ears  should  be  kept  closed  with 
cotton  and  the  eyes  covered  with  a 
towel  or  cloth. 

The  results,  as  far  as  they  go,  would 
tend  to  support  the  view  that  spinal 
antesthesia  is  not  very  dangerous,  ex- 
cept perhaps  to  the  child  in  utero. 
When  it  produces  disagreeable  symp- 
toms, they  are  usually  transient.  In 
the  labor  cases  it  usually  retarded 
progress.  Finally,  the  anaesthesia  it 
produces  is  for  a  fairly  definite  period 
of  time  without  affecting  consciousness 
and  with  full  control  of  the  voluntary 
muscles. 

From  a  study  of  these  cases  the  iise 
of  the  lumbar  puncture  in  multiparte 
would  seem  to  be  less  called  for  than 
inhalations  of  chloroform.  The  results 
obtained  from  its  use  in  primiparse  were 
also  not  very  encouraging,  but  when 
good  results  can  be  obtained  in  a  few 
cases  the  experiments  should  be  con- 
tinued. 

It  is  doubtful  if  the  puncture  will  ever 
replace  general  narcosis  in  abdominal 
operations.  In  vaginal  cceliotomy  and 
minor  gyntecological  work  it  seems  to 
have  its  greatest  field  of  usefulness,  and 
will,  it  is  believed,  come  more  in  vogue 
as  its  merits  are  more  fully  observed 
and  understood.  N.  J.  Ilawley  and  F. 
J.  Taussig  (Med.  Record,  Jan.  19,  1001). 

It  is  contra-indicated  in  children  and 
in  nervous  and  timid  patients,  particu- 
larly women;  also  in  operations  de- 
manding muscular  relaxation,  such  as 
those  for  the  reduction  of  fracture  and 
dislocation,  and  in  cases  of  difficult  and 
prolonged  laparotomy.  In  women,  par- 
ticularly those  who  are  young  and  nerv- 
ous, lumbar  anaesthesia  is  not  satisfac- 
tory, as  it  is  so  liable  in  such  subjects 
to  give  rise  to  intense  discomfort  and  a 
very  rapid  pulse,  and  to  be  followed  by 
obstinate  vomiting  and  severe  and  pro- 
longed   headache.      It    should    only    be 


252 


COCA  A^'D  COCAINE.    LOCAL  AX.ESTHESL4. 


used  in  female  patients  who  are  calm 
and  free  from  timidity,  and  in  cases  in 
which  general  anjesthesia  is  contra- 
indicated.  Chaput  (Bull,  et  Mem.  de  la 
Soc.  de  Chir.  de  Paris,  Apr.  30,  1901). 

Conclusions  based  on  fifty  eases  of 
spinal  analgesia:  1.  Cocaine  is  far  more 
satisfactory  than  eucaine.  The  latter  is 
less  potent,  more  evanescent,  the  areas 
of  analgesia  are  frequently  "patchy," 
having  the  pain-sense  retained  all 
around  them  and  not  being  so  complete 
below  definite  levels.  The  cocaine  pro- 
duces no  more  unpleasant  after-effects 
than  eucaine,  and  is  decidedly  more  re- 
liable. 2.  Analgesia  to  the  level  of  the 
diaphragm  can  be  depended  upon  in  all 
cases  where  a  moderate  dose  of  a  potent 
solution  of  cocaine  has  been  introduced 
by  lumbar  puncture.  In  some  the  anal- 
gesia is  sufficient  for  operation  on  the 
upper  extremities.  3.  Complete  anal- 
gesia— including  the  eyes,  mouth,  and 
throat — has  occurred.  It  does  not  en- 
tail more  severe  after-effects  than  when 
the  lower  extremities  only  are  involved. 
4.  The  preparation  of  the  patient  as  for 
a  general  anaesthetic  diminishes  all  the 
unpleasant  effects  of  cocaine  and  eucaine 
and  often  prevents  them  altogether.  5. 
By  moderate  doses  of  bromides  before 
the  injection  the  initial  vomiting  is  fre- 
quently avoided  and  the  liability  of 
headache  lessened.  6.  In  neurotic  pa- 
tients there  are  often  hysterical  symp- 
toms directly  following  the  completion 
of  the  injection,  but,  as  a  rule,  in  a  few 
moments  a  calm  follows  and  the  patient 
lies  perfectly  still.  7.  Initial  nausea  and 
vomiting  often  occur  soon  after  the 
puncture,  but  last  only  for  a  moment  or 
two,  and  usually  do  not  recur  during 
the  operation.  As  consciousness,  as  well 
as  the  muscular  power,  is  preserved,  the 
danger  of  the  introduction  of  the  vomi- 
tua  into  the  lungs  is  practically  till.  8. 
Analgesia  lasts  from  30  minutes  to  4 
hours.  9.  Depression  after  the  puncture 
is  inconsiderable.  The  use  of  ethyl- 
chloride  (Bcngue)  largely  prevents  pain 
when  the  needle  is  introduced.  10.  The 
preparation  of  the  patient,  the  use  of 
nitroglycerin  by  hypodermic  injection, 
or  the  employment  of  coal-tar  products 
with     caffeine,    control     the     headache, 


which  is  in  many  instances  an  after- 
effect of  spinal  pimcture.  11.  In  a  few 
cases  there  may  be  motor  paraplegia  or 
vertigo.  Both  are  temporary.  12. 
Spinal  puncture  has  not  affected  normal 
or  diseased  kidneys.  13.  L^sually  the 
tactile  power,  muscular  sense,  and  the 
ability  to  detect  heat  and  cold  are  re- 
tained. The  cautery  at  a  dull-red  heat 
causes  no  pain,  while  hot  water  pro- 
duces marked  discomfort.  14  Usually 
the  patient  sleeps  the  first  night.  15. 
There  is  often  a  temperature  of  a  few 
degrees  within  eight  or  ten  hours  of  the 
operation.  Whether  this  is  the  direct 
result  of  the  puncture  or  the  effect  of 
psychical  disturbances  is  not  deter- 
mined. The  circulation  and  respiration 
are  not  seriously  embarrassed.  W.  S. 
Bainbridge  (Med.  News,  May  4,  1901). 

Series  of  40G  cases  operated  on  under 
this  method  of  anesthesia  without  a 
death.  A  solution  of  from  1  to  2  centi- 
grammes (Vo  to  '/,  grain)  of  cocaine, 
made  up  with  cerebro-spinal  fluid  which 
had  previously  been  withdrawn  by  punct- 
ure, was  used  in  all  the  cases.  Although 
there  have  been  no  fatal  cases,  the 
author  has  observed  nearly  all  the  un- 
pleasant sequelte,  such  as  headache,  etc. 
The  method  has  proved  satisfactory,  but 
should  not  be  used  in  the  presence  of 
contra-indications.  Sequen  in  his  last 
series  of  cases  reports  2  deaths.  In  1 
there  was  an  incarcerated  hernia  with 
the  phenomena  of  septicajmia,  while  in 
the  other  arteriosclerosis  was  present. 

In  the  discussion  which  followed  Jon- 
nesco  stated  that  he  used  the  method  in 
only  8  cases,  and  in  1  of  these  with  a 
fatal  result;  no  arteriosclerosis  nor 
organic  lesions  were  present,  and  death 
was  attributed  directly  to  the  cocaine. 
The  author  has  abandoned  this  method, 
for  the  reason  that  its  mortality  is 
higher  than  ether  or  chloroform,  and 
the  aftereffects,  as  a  rule,  are  severe. 
Raeoviceano-Pitesci  (Bull,  et  MCm.  do 
la  Soc.  de  Chir.  de  Bucarest,  Dec,  1901). 

The  injection  of  sterilized  water  into 
the  arachnoid  sac  accomplishes  the  same 
antpsthesia,  but  is  apt  to  cause  the  same 
(Hi-iilcnt  as  the  sul)araehnoid  injection 
of  cocaine  in  the  treatment  of  sciatica. 
For  subarachnoid  use,  aqueous  solutions 


COCA  AND  COCAINE.    TOPICAL  ADMINISTRATION. 


253 


of  cocaine  should  not  be  diluted  with 
water;  after  the  injection,  patients 
must  be  kept  in  bed  for  from  two  to 
three  days.  M.  Guinard  (Jour,  des 
Praticiens,  March  22,  1902). 

Adrenalin  diminishes  the  poisonous 
effect  of  cocaine  and  it  increases  the 
latter's  antcsthetic  power  in  duration, 
in  intensity,  and  in  area.  By  intradural 
injections  into  cats  he  found  that  the 
simultaneous  injection  of  cocaine  and 
adrenalin  diminished  the  to.xicity  of  the 
former  one-third,  and,  by  the  previous 
injection  of  adrenalin,  by  ono-lifth.  The 
aneemia  caused  by  the  adrenalin  is  not 
so  dangerous  to  the  sensitive  ner\'ous 
elements  as  the  poison  of  the  cocaine. 
In  man,  no  bad  symptoms  were  noted, 
and  the  author  is  hopeful  that  the  new 
method  will  entirely  supplant  the  for- 
mer method  of  using  cocaine  alone  for 
intradural  anaesthesia.  Diinitz  (Miinch- 
ener  med.  Wochen.,  Aug.  25,  1903). 

Corning  emphasizes  the  following  pre- 
cautions: The  puncture  must  not  be 
made  in  the  operating-room.  The 
needle  must  be  very  thin,  the  solution 
one  of  2-per-cent.  of  cocaine  hydrochlo- 
rate.  The  patient  should  sit  up,  and  the 
puncture  should  then  be  made  on  the 
level  of  the  crests  of  the  ilium.  The  in- 
jection should  be  made  very  slowly,  tak- 
ing a  mintite  for  injecting  15  minims  of 
the  liquid.  The  most  common  disad- 
vantages of  this  method  are  vomiting 
during  operation  and  headache  after- 
ward. Six  cases,  out  of  2000  operations, 
died  after  lumbar  puncture,  3  of  them 
with  tuberculous  meningitis. 

Cocainization  of  the  spinal  cord  has 
been  carried  out  on  02  occasions  in  the 
clinic  of  von  Mikulicz.  In  40  cases  the 
analgesia  was  complete,  in  9  it  was  in- 
complete, and  in  12  there  was  none  at 
all.  The  injections  were  frequently  fol- 
lowed immediately  by  such  symptoms 
as  sickness,  vomiting,  profuse  sweating, 
a  feeling  of  general  oppression,  and 
tremors  all  over  the  body.  Twice  there 
was  genuine  collapse.  Among  the  un- 
toward   after-effects    were    continuous 


vomiting,  pains  in  the  loins  and  back, 
and  severe  headache.  On  several  occa- 
sions there  was  retention  of  urine.  The 
unreliability  of  the  method  and  the  oc- 
currence of  these  unpleasant  symptoms 
have  led  to  the  abandonment  of  the  in- 
jection of  cocaine  into  the  spinal  canal 
at  von  ilikulicz's  clinic.  (Beitriige  z. 
klin.  Chir.,  Bd.  xx.\v,  H.  2,  1903.) 

Topical  Administration. — Cocaine  is 
applied  locally  to  the  mucous  membranes 
and  the  skin  for  the  relief  of  pain,  to  in- 
duce local  anaesthesia  for  operative  pur- 
poses, to  control  haemorrhage,  and  for 
diagnostic  purposes.  When  applied  lo- 
cally to  a  mucous  membrane,  cocaine 
causes  a  temporary  blanching  and  shrink- 
age, with  an  anjesthetic  condition  of  the 
part.  The  former  are  due  to  a  construc- 
tion of  the  blood-vessels,  the  latter  to  a 
paralysis  of  the  peripheral  filaments  of 
the  sensory  nerves.  The  anemia  pro- 
duced is  only  temporary,  and  is  followed 
by  a  marked  congestion.  For  therapeutic 
study  we  will  observe  the  application  of 
the  remedy  on  the  various  organs,  noting 
at  the  same  time  the  strength  of  the  solu- 
tions generally  used  in  each  case. 

If  a  40-per-cent.  freshly  prepared  so- 
lution of  cocaine  is  applied  from  one  to 
one  and  a  half  hours  to  the  unbroken 
skin,  there  results  a  local  antesthesia. 
Circumcision  accomplished  without  pain 
by  the  simple  external  application  of  a 
40per-cent.  solution  of  cocaine.  Before 
the  operation  the  parts  were  carefully 
cleansed  of  all  sebaceous  and  oily  mat- 
ter, and  well  dried  after  the  thorough 
use  of  an  antiseptic.  Then  a  solution  of 
cocaine  was  applied  to  the  line  of  in- 
cision by  means  of  a  pledget  of  ab- 
sorbent cotton.  The  saturated  cotton 
was  kept  in  contact  with  the  parts  for 
twenty  minutes,  when  it  was  removed 
and  the  part  allowed  to  dry  for  ten 
minutes.  The  cocaine  was  then  reap- 
plied, and  this  was  continued  for  from 
one  to  one  and  a  half  hoiirs.  The  skin 
may  be  quite  as  effectually  aniesthetizcd 
by  this  method  as  by  hypodermic  injec- 
tions of  cocaine,  it  only  being  necessary 


254 


COCA  AND  COCAINE.    TOPICAL  ADMINISTRATION. 


to  keep  the  solution  sufficiently  long  in 
contact  with  the  parts.  After  such  an 
application  of  cocaine  numbness  will 
persist  in  the  skin  for  from  four  to  five 
hours.  W.  P.  Beach  (Brooklyn  Med. 
Jour.,  July,  1901). 

Cocaine  should  not  be  given  for  over- 
coming pain  in  the  eye,  because  its 
effect  is  only  temporary.  The  patients 
drop  it  in  the  eye  too  often,  and  cor- 
neal injuries  result.  For  operation  or 
with  conjunctival  injection  the  author 
uses  cocaine,  with  suprarenal  extract 
and  morphine  hypodermically.  Schleich' 
infiltration  anaesthesia  is  not  recom 
mended  for  operations  on  the  eyelid 
Cocaine  is  useful  for  photophobia  and 
mydriasis.  In  place  of  cocaine  for  con- 
trolling the  pain,  warm  or  cold  com 
presses,  leeches,  or  dionin  are  ordered 
Fuchs  (Wiener  klin.  Wochen.,  Sept.  18, 
1902). 

Eye. — For  use  as  an  anesthetic  in  the 
eye  cocaine  in  solution  of  from  1  per  cent, 
to  i  per  cent,  in  strength  may  be  em- 
ployed, 1  to  5  or  more  drops  being  in- 
stilled. All  operations  of  a  painful  char- 
acter, the  pain  of  an  acute  inflammation, 
or  that  caused  by  the  presence  of  a  for- 
eign body  are  indications  for  cocaine. 
Its  use  in  keratitis  is  not  advised  in  that 
it  has  produced  permanent  opacities  in 
the  cornea. 

Nose,  Pharynx,  and  Larynx. — The 
application  of  cocaine  (5  per  cent,  to  20 
per  cent.)  in  the  mucous  membrane  of 
these  parts  is  useful  not  only  for  thera- 
peutic purposes  and  operations,  but  also 
for  purposes  of  examination  and  diag- 
nosis. 

Before  scarifications,  etc.,  cocaine  may 
be  applied  in  a  powder;  cocaine  hydro- 
chloride, magnesium  carbonate,  2 '/, 
drachms.  A  moist  compress  is  laid  out- 
side, for  ten  minutes,  which  the  patient 
is  instructed  to  press  lif,'litly  against  the 
part.  If  the  skin  is  intact,  pure  basic 
cocaine  must  be  used  instead.  Unna 
(.Tour.  Amer.  Med.  Assoc,  Apr.  30,  'OS). 
The  following  solution  of  cocaine  is 
stable:  — 


B  Cocaine  hydrochlorate,  4  grains. 
Distilled  water,  2  '/j  drachms. 
Salicylic  acid,  Vo  grain. 
Editorial    (Jour,    de   M6d.    de   Paris; 
Phila.  Med.  Jour.,  May  2G,  1900). 

The  natural  sensitiveness  of  the  parts 
is  obtunded  by  the  anjesthesia  induced; 
the  shrinkage  of  the  soft  parts  induced 
by  the  contraction  of  the  blood-vessels 
makes  more  prominent  the  distinction 
between  hypertrophy  of  the  soft  tissues 
and  tumors  of  cartilaginous  or  bony 
character;  again,  by  temporarily  controll- 
ing the  hfemorrhage  (by  contraction  of 
the  blood-vessels)  and  the  shrinkage  of 
the  soft  parts,  the  field  of  operation  is 
made  more  clear  and  open.  Nasal  and 
laryngeal  polypi  are  more  easily  diag- 
nosed and  removed,  and  operations  on 
the  uvula,  tonsils,  epiglottis,  and  larynx 
are  facilitated.  The  Eustachian  catheter 
is  more  easily  introduced  after  the  appli- 
cation of  a  solution  of  cocaine  to  the 
nasal  cavities  and  the  naso-pharynx.  In 
acute  coryza  or  rhinitis  the  insuffla- 
tion every  two  hours  of  a  small  portion 
of  a  powder  consisting  of  cocaine  muri- 
ate, 1  part;  bismuth  subcarbonate,  5 
parts;  and  talc,  15  parts,  is  useful.  An- 
other formula  for  the  same  uses  consists 
of  cocaine  and  morphine,  1  part  of  each; 
bismuth,  5  parts;  used  as  snufE  like  the 
preceding. 

Cocaine  carbolate  has  been  recom- 
mended in  nasal  catarrh  and  ozfcna, 
either  pure  or  5-  to  lO-per-ccnt.  solutions 
in  alcohol  or  spirit  of  ether,  or  1-pcr-cent. 
solution  in  diluted  alcohol  containing  70 
per  cent,  of  water  on  cotton  or  by  instil- 
lation, or  5-  to  10-per-cent.  triturations 
with  acetanilid  or  boric  acid  for  insuffla- 
tion. 

Cocaine  solution  is  also  used  to  anocs- 
thetizo  ulcers  or  hypertrophies  previous 
to  the  application  of  acids  or  instru- 
montfi.  Liquid  applications  may  lie 
made  Ijy  means  of  cotton  pledgets  dipped 


COCA  AND  COCAINE.    TOPICAL  AD.MIXISTRATIOX. 


255 


in  the  cocaine  solution  by  the  spray  of  an 
atomizer;  in  powder  by  insufllation  as 
above. 

GENiTO-UitiNARY  Teact. — The  injec- 
tion of  a  few  drops  of  a  2-per-cent.  solu- 
tion of  cocaine  renders  catheterization 
easy  and  painless,  provided  there  is  no 
stricture.  Operations  on  the  bladder 
(lithotrity,  litholapaxy,  catheterization 
of  ureters,  etc.)  are  rendered  painless 
through  previous  injections  of  cocaine. 
Weak  solutions  (not  strong,  the  2  per 
cent.)  must  be  used,  as  fatal  poisoning 
has  followed  the  injection  of  5  drachms 
of  a  5-per-eent.  solution  into  the  urethra. 

Wittsack,  of  Frankfort,  advises  the 
use  of  lactate  of  cocaine  in  the  treatment 
of  tubercular  cystitis.  He  instills  a  solu- 
tion containing  15  grains  of  cocaine 
lactate  and  75  minims  each  of  lactic  acid 
and  sterilized  distilled  water,  previously 
emptying  the  bladder,  but  not  washing 
it  out. 

GYNiECOLOGY. — For  application  to  the 
mucous  surfaces  of  the  vulva,  vagina, 
and  the  uterine  cavity,  stronger  solutions 
(10  per  cent,  to  20  per  cent.)  are  used. 
Here,  as  elsewhere,  the  use  of  cocaine 
anaesthesia  should  be  confined  to  minor 
operations  (curettage,  dilatation  of  cer- 
vix, removal  of  uterine  polyps,  etc.).  In 
operations  extending  below  the  surface 
parenchymatous  injections  should  sup- 
plement the  applications  to  the  mucous 
surface. 

Eectum. — The  anaesthetic  solution  (5 
per  cent.)  is  here  applied  to  the  mucous 
membrane  by  means  of  pledgets  of  ab- 
sorbent cotton  saturated  with  the  solu- 
tion. Parenchymatous  injections  may 
also  be  needed.  In  major  operations  or 
in  complicated  ones,  general  ana?stliesia 
is  advised. 

Skin. — The  topical  application  of 
cocaine  has  been  suggested  for  the  cure 
of  cracked  and  fissured  nipples,  but  is 


not  advisable,  as  through  its  use  lactation 
may  be  interfered  with.  This  latter 
suggests  the  use  of  a  5-per-cent.  solution 
of  cocaine  made  with  equal  parts  of  glyc- 
erin and  water  as  a  solvent  to  inhibit 
lactation  or  cause  its  complete  cessation. 
The  glands  are  bathed  four  or  five  times 
daily  with  the  solution  and  supported  by 
means  of  a  bandage. 

In  zona  cocaine  not  only  relieves  tlie 
pains,  but  also  causes  a  regression  of  the 
eruption,  bringing  about  its  disappear- 
ance in  the  course  of  a  few  days. 
Twenty-three  cases  thus  cured.  The 
aflected  surface  is  painted  with  equal 
parts  of  wool-fat  and  (wtrolatuni  rubbed 
up  together  with  I  per  cent,  of  cocaine 
hydrochlorate,  and  dressed  with  linen 
spread  with  the  same  ointment.  Bleuler 
(Nouveau.x  RemJdes,  No.  I,  1900). 

Incidentally  it  may  be  noted  that 
Geley,  of  Bordeaux,  has  found  that 
cocaine  has  an  antipyretic  action  when 
applied  to  the  skin,  provided  the  appli- 
cations be  made  at  a  time  when  the  tem- 
perature is  no  longer  rising.  This  action 
is  analogous  to  that  of  guaiacol,  though 
less  marked. 

Cocaine  introduced  by  cataphoresis. 
Solution  recommended  consists  of  cocaine 
(the  alkaloid,  not  the  hydrochlorate),  6 
grains,  dissolved  in  a  drachm  of  guaiacol. 
If  a  little  of  this  mi.xture  upon  a  piece 
of  blotting-paper  is  placed  on  the  skin, 
and  a  current  applied  through  it,  the  co- 
caine quickly  penetrates,  and  local  antcs- 
thcsia  can  be  produced  in  about  four  or 
five  minutes.  The  positive  electrode 
should  be  placed  on  the  blotting-paper. 
It  should  consist  of  a  flat  disk  of  bare 
metal  of  suitable  size.  A  platinum  sur- 
face is  the  best,  but  tin  or  any  other 
metal  which  docs  not  easily  become  cor- 
roded "ill  do  almost  as  well.  Care  must 
be  taken  that  the  metal  itself  does  not 
touch  the  skin  at  any  point.  The  cur- 
rent is  then  turned  on  until  it  reaches 
about  4  milliampi^res  for  an  electrode 
half  an  inch  in  diameter.  At  first  from 
10  to  1.5  cells  are  necessary  to  produce 
this  current,  for  the  solution  has  a  high 


256 


COCAIXOMAXIA.    VAKIETIES.    SYMPTOMS. 


resistance;  but  soon  conduction  im- 
proves, and  the  number  of  cells  may  be 
reduced.  H.  Lewis  Jones  (Clinical  Jour., 
Mar.  8,  '99). 

C.   SUilXER  WiTHERSTINE, 

Philadelphia. 

COCAINOMANIA,  OE  COCAINE 
HABIT. 

Definition. — Cocainomania  is  an  irre- 
sistible craze,  crave,  or  impulse  to  intox- 
ication by  cocaine,  or  any  of  its  salts 
or  combinations,  at  all  risks.  Unless  a 
cure  of  the  "habit,"  or,  more  accurately, 
the  disease  of  cocainomania  be  effected, 
the  cocaine  habitue  cannot  refrain  from 
resorting  to  the  employment  of  the  drug, 
if  a  supply  can  possibly  be  procured, 
whenever  the  craze,  crave,  or  impulse 
seizes  upon  him. 

Varieties. — The  two  leading  types  of 
the  cocaine  habit  are  (1)  periodical; 
(2)  continuous.  In  the  former  the 
halitue  will,  after  an  outbreak  of  cocaine 
intoxication,  go  on  without  cocaine  in 
any  form  for  a  longer  or  shorter  interval, 
till  a  condition  of  mental  unrest,  aris- 
ing sometimes  apparently  from  within, 
ushers  in  a  period  of  more  or  less  com- 
plete temporary  abandonment  to  the 
drug.  Sometimes  the  outburst  is  in- 
augurated by  a  recurrence  of  the  acute 
pain,  or  the  asthma,  or  other  physical 
trouble,  for  the  assuagement  of  which 
the  poison  was  originally  taken.  In 
some  highly-strung  women  the  menses 
act  as  the  exciting  provocative,  partic- 
ularly when  accompanied  by  acute  dys- 
menorrhoea.  In  the  latter  variety,  the 
continuous,  the  unfortunate  victim 
keeps  on  steadily  taking  the  drug  daily 
in  rapidly-increasing  quantities  till  he  or 
she  is  rendered  incapable  of  exertion, 
sometimes  of  connected  t]iniif.'lit.  by  ad- 
vancing paralysis  or  by  insanity.  In 
some  instances  the  indulgence  is  social, 
in  others  solitary,  the  latter  being  the 


rule  and  the  former  the  exception. 
Some  variation  is  observable  when  co- 
caine addiction  is  associated  with  alco- 
holic or  other  narcotic  indulgence.  In 
this  way  the  addiction  may  be  double, 
triple,  or  fourfold:  twofold,  as  alcohol 
or  morphine  with  cocaine;  threefold,  as 
with  alcohol  and  chloral;  fourfold,  as 
with  alcohol,  morphine,  and  chloral. 

Symptoms. — On  taking  a  fresh  dose, 
in  chronic  cocainomania,  there  are,  gen- 
erally within  ten  minutes,  exuberance  of 
spirits,  quickened  pulse,  general  accelera- 
tion of  the  circulation,  talkativeness, 
restlessness,  hallucinations,  with  rapid 
and  somewhat  spasmodic  breathing,  in- 
tense joyous  activity,  and  a  remarkable 
overconfidence  in  one's  capacities  and 
strength.  Even  when  actually  weaker, 
during  the  cocaine-delirious  intoxica- 
tion, the  taker  feels  infinitely  stronger 
and  more  agile.  Occasionally  there  is 
vertigo,  with  some  confusion  of  the  in- 
tellectual faculties.  There  is  usually 
great  cerebral  excitement,  with  dilated 
pupils,  throat  dryness,  and  headache,  the 
last  named  frequently  not  severe  enough 
to  be  painful.  There  is  a  rise  of  tem- 
perature, with  a  loss  of  the  sense  of  time, 
though  memory  is  usually  intact.  De- 
pression and  prostration  follow  very 
often.  When  the  dose  has  been  rela- 
tively moderate, — i.e.,  not  larger  than  the 
cocaine-taker  has  been  gradually  accus- 
tomed to  take, — the  period  of  nervous 
hyperexcitation  has  passed  away  by  from 
half  an  hour  to  two  hours.  AVhen  the 
dose  taken  has  been  relatively  immod- 
erate, the  depression  and  nervous  debil- 
ity may  remain  for  days  or  till  the  next 
dose. 

In  chronic  cocaine  poisoning,  though 
some  habitual  cocainists  do  not  appear 
to  show  any  symptoms  of  injured  health 
or  vigor,  others  appear  wasted,  with  pale- 
yellowish  skin,  the  extremities  clammy, 


COCAINOMANIA.    SYMPTOMS. 


257 


with  cold  perspiration.  The  eyes  are 
glistening  and  sunken  with  dark,  sub- 
ocular  rings,  the  pupils  being  dilated. 
Anorexia  and  impaired  digestion  are 
present,  with  palpitation,  dyspncca,  tin- 
nitus aurium,  tremors,  neurasthenia,  and 
uncertainty  of  step.  Hallucinations, 
especially  of  sight  and  hearing;  mis- 
trust; delusions  of  persecution;  and 
general  paralysis  sometimes  end  the 
scene.  Yet,  in  some  cases,  one  sees  occa- 
sional spells  of  brightness,  brilliance, 
and  mental  activity. 

[The  effects  of  clironic  cocaine  intox- 
ication are  as  follows:  Physically  there 
is  the  rapidly-developing  marasmus  so 
characteristic  of  chronic  cocaine  intox- 
ication. Psychically  we  find  feelings  of 
apprehension;  delusions,  chiefly  of  per- 
secution; and  hallucinations,  visual  or 
sensory.  Frightful  forms  appear  every- 
where, or  small  living  things  creep  upon 
the  skin.  Insomnia,  loss  of  appetite, 
and  impotence  complete  the  picture  of 
coeainism.  Ohersteiner,  Corr.  Ed.,  An- 
nual.] 

Three  cases  of  chronic  coeainism  in 
which  the  predominant  symptoms  were 
those  relating  to  general  sensibility,  con- 
sisting chiefly  of  hallucinations  produc- 
ing a  sensation  as  if  foreign  bodies  were 
under  the  skin.  The  first,  a  merchant 
aged  48,  was  continually  sciaping  his 
tongue,  imagining  that  it  was  filled  with 
small,  black  worms,  and  picking  the 
skin  to  find  choleraic  microbes.  The 
second,  a  pharmacist,  attempted  to  ex- 
tract microbes  from  his  skin  with  his 
nails  and  with  a  needle.  The  third,  a 
physician,  sought  for  crystals  of  cocaine 
under  the  skin.  Hallucinations  of  cu- 
taneous sensibility  are  fir.st  to  develop; 
hallucinations  of  vision,  hearing,  taste, 
and  smell  occur  later.  Disturbances  of 
ideation,  as  delirium,  are  consecutive  to 
the  hallucinations.  The  latter  are  less 
active  than  those  prod\iccd  by  alcohol 
or  absinthe.  Epileptiform  attacks  oc- 
curred with  two  of  the  patients  and 
cramps  in  the  third.  Toxic  epilepsies, 
when  there  is  no  predisposition,  disap- 
pear with  the  cause.    Magnan  and  Saury 


(La  Tribune  Mfidicale,  Feb.  3,  Mar.  28, 
'89). 

Aphrodisiac  effects  of  cocaine  shown 
in  the  case  of  a  woman,  married  and 
highly  respectable,  who  became  a  victim 
of  cocaine,  and  who,  while  under  its  in- 
fluence, would  invariably  utter  expres- 
sions and  do  things  which  she  would 
not  even  have  thought  of  when  in  her 
normal  condition.  These  effects  appear 
to  be  more  pronounced  in  females  than 
in  males,  and  hence  the  inadvisability  of 
the  indiscriminate  use  of  cocaine.  M.  K. 
Bowers   (Med.  Age,  Dec.  20,  '91). 

Case  of  chronic  coeainism,  in  which  the 
patient  sutTered  from  hallucinations,  un- 
der the  influence  of  which,  according  to 
his  statement,  he  twice  committed  as- 
saults. Regarded  as  a  case  of  cocaine 
epilepsy,  on  account  of  the  suddenness 
of  his  attacks  of  furor  and  a  certain 
amount  of  amnesia.  He  formed  the 
habit  by  using  it  for  a  nasal  trouble. 
Lewin  (Deutsche  med.-Zeit.,  Jan.  1,  '91). 

Magnan's  sign — an  hallucination  of 
cutaneous  sensibility,  characterized  by  a 
sensation  of  foreign  bodies  under  the 
skin,  which  are  described  as  inert  and 
spherical,  varying  in  size  from  a  grain 
to  a  nut,  or  as  living  organisms,  worms, 
bugs,  etc. — observed  in  two  cases.  Ri- 
bakoff  (Gaz.  degli  Ospedali  e  delle  Clin., 
Aug.  4,  '96). 

The  first  feeling  a  cocainist  has  is  an 
indescribable  excitement  to  do  some- 
thing great,  to  leave  a  mark.  But  this 
disappears  as  rapidly  as  it  came.  The 
second  sensation — at  first,  at  least,  no 
hallucination — is  that  his  hearing  is 
enormously  increased.  Very  soon  every 
sound  begins  to  be  a  remark  about  him- 
self, mostly  of  an  offensive  kind,  and  he 
begins  to  carry  on  a  solitary  life,  his 
only  companion  being  his  syringe.  Every 
passer-by  seems  to  talk  about  him.  After 
a  relatively  short  time,  he  begins  the 
"hunting  of  the  cocaine  bug,"  and  im- 
agines that,  in  his  skin,  worms  or  sim- 
ilar things  are  moving  along. 

Personal  opinion  that  there  is  a  ques- 
tion of  disturbance  in  the  frontal  cortex, 
originating,  perhaps,  in  skin  dysjEsthe- 
siir,  and  not  a  simple  visual  hallucina- 
tion or  retinal  projection.  Springthorpe 
(Quarterly  Jour,  of  Inebriety,  Jan.,  '97). 


258 


COCAINOMANIA.     DIFFEKENTLAL  DIAGNOSIS. 


In  acute  cocaine  poisoning  there  may, 
or  may  not,  be  the  exhilaration  stage, 
the  poisoned  sometimes  falling  rapidly 
into  collapse  and  insensibility  after  ex- 
ceedingly transient  symptoms  of  pale- 
ness, faintness,  fullness  of  head  and 
giddiness,  skin  creepings,  profuse  per- 
6piration,  praecordial  distress,  rapid  hard 
or  weak  pulse,  loquacity,  restlessness, 
agitation,  and  hysterical  excitement. 
The  pupils  are  dilated  and  dull,  the  per- 
spiration, at  first  quickened,  becomes 
spasmodic  and  labored,  unconsciousness 
sets  in,  convulsive  seizures  appear  after 
muscular  cramps,  sometimes  with  tetanic 
spasms,  followed,  it  may  be,  by  deepen- 
ing cyanosis,  violent  delirium,  enuresis, 
and  paralysis  of  the  sphincters.  Withal 
there  are  often  localized  areas  of  anaes- 
thesia. In  non-fatal  cases,  though  the 
acute  symptoms  may  pass  off  in  a  couple 
of  hours  or  so,  feelings  of  languor, 
malaise,  and  local  pains  may  linger  for 
days. 

Differential  Diagnosis. — Though,  in 
many  cases,  unless  the  presence  of  co- 
caine can  be  determined  by  finding  the 
drug  or  by  the  brown  stain  over  the  seats 
of  hypodermic  injection,  this  particular 
"habit"  or  mania  cannot  be  diagnosed 
from  other  forms  of  narcotic  addiction, 
there  are  one  or  two  prominent  symp- 
toms which  point  to  cocaine  as  the  spe- 
cial mania.  Especially  in  the  earlier 
stages,  though  to  a  larger  extent  in  the 
more  advanced,  alcohol  is  excluded  by 
the  absence  of  symptoms  pointing  to 
organic  functional  bodily  lesion.  The 
cocainomaniac  not  only  often  shows  no 
symptom  of  bodily  or  mental  disturb- 
ance, but  manifests  simply  a  sense  of 
satisfaction,  and  an  appearance  of  in- 
creased capacity  for  intellectual  and 
muscular  work.  In  many  cases  the 
closest  physical  examination  lias  failed 
to  reveal  anything  abnormal.    Indeed,  at 


times  the  only  symptom  discernible  has 
been  an  apparently  improved  condition. 
In  some  instances  only  the  closest  con- 
tinuous scrutiny  of  a  business  partner 
or  a  wife  has,  after  a  time,  disclosed 
even  the  slight  falling  off  in  the  char- 
acter of  the  work  and  of  the  judgment, 
the  actual  amount  of  work  having  been 
occasionally  increased.  One  point  of 
differentiation,  even  from  etheromania 
(which  is  more  speedy  in  the  appearance, 
progress,  and  cessation  of  toxic  symp- 
toms than  either  alcohol,  opium,  mor- 
phine, chloral,  or  chloroform),  is  the 
greater  quickness  with  which  the  char- 
acteristic phenomena  of  cocaine  poison- 
ing set  in  and  pass  away.  Still  another 
discriminating  symptom  is  the  extra- 
ordinary self-confidence  and  elation 
arising  from  cocaine.  In  etheromania 
the  odor  of  the  breath  is  characteristic, 
and  the  activity  more  effervescent  and 
demonstrative.  A  point  of  distinction 
from  alcoholomania  is  that,  while  this  is 
mostly  social  and  less  often  solitary, 
cocainomania  is  almost  always  solitary. 
Yet  another  difference  from  alcohol  and 
morphine  is  that  the  prevailing  delusions 
of  cocainomania  are  delusions  of  perse- 
cution. These  rarely  occur  with  alco- 
hol, except  temporarily  sometimes  in 
delirium  tremens  or  in  chronic  alcohol- 
ism, and  still  less  often  with  morphino- 
mania.  They  are  frequently  seen,  how- 
ever, with  the  chronic  cocaine  habit,  and 
are  at  once  more  marked  and  more  per- 
sistent with  cocaine. 

Alcoholism.  —  The  subject  of  this 
disorder  shows  greater  evidence  of  mor- 
bid change;  the  subjective  and  objective 
symptoms  are  more  marked.  There  is 
distinct  attraction  for  social  pleasures, 
whereas  the  narcomaniac  prefers  soli- 
tude. 

MoRPHiNOMANiA.  —  Characteristic 
symptoms   set   in   and    disappear   more 


COCAINOIIANIA.    ETIOLOGY. 


259 


quickly.  Cocainomania  is  characterized 
by  marked  self-confidence  and  elation. 

Etheromania.  —  The  odor  of  the 
breath  is  characteristic  and  the  activity 
more  effervescent  and  demonstrative. 

Etiology. — The  chief  predisposing  in- 
fluence is,  undoubtedly,  the  neurotic 
diathesis.  On  the  nervo-sanguine  and 
passionate  temperaments  cocaine  has  a 
special  excitant  power.  Once  taken  in 
any  form  for  the  assuaging  of  acute 
pain,  on  such  temperaments  this  drug 
fastens  as  if  with  a  grip  of  iron  im- 
bedded in  velvet.  In  one  case  of  a  life- 
abstainer  from  alcohol,  cocaine,  taken 
once  during  a  prostrating  attack  of 
agonizing  pain,  exercised  so  powerful  a 
hold  that  only  after  a  strenuous  struggle 
of  over  a  week's  duration  could  the  vet- 
eran nephalist  overcome  the  imperious 
impulse  to  take  a  second  dose.  He  felt 
that,  if  he  yielded,  his  will  would  have 
been  rendered  powerless  for  the  future 
against  the  tremendous  fascination  of 
the  drug  M'hich  has  banished  his  pain 
as  if  by  magic,  and  of  the  name  and 
other  properties  of  which  he  was  utterly 
ignorant.  In  "neurotics"  I  have  seen  a 
few  doses,  taken  medicinally,  set  up  the 
"cocaine  habit."  In  transmitted  gout, 
with  irritable  and  susceptible  brain  and 
nervous  system,  this  special  predisposi- 
tion has  been  markedly  present.  It  has 
also  been  noted  in  syphilis  and  scrofula 
with  cerebral  complication.  Epileptic 
neuroses  have  been  greatly  in  evidence. 

Exciting  Influences.  —  Over  and 
above  the  psychological  excitation  of  the 
drug  itself,  the  exciting  causes  seen  by 
me  have  practically  been  confined  to 
urgent  clamor  for  relief  from  physical 
agony,  such  as  occurs  at  times  in  asthma 
or  neuralgia. 

Cocaine,  which  has  b\it  recently  been 
introduced  in  India,  is  generally  taken 
in  the  form  of  powder  sprinkled  on  a 


paste  of  slaked  lime,  which  is  buttered 
on  a  betel-leaf.  The  mass  is  rolled  up 
and  chewed  for  about  fifteen  minutes. 
The  first  symptom  of  the  so-called 
hilarity  is  a  heaviness  of  the  head. 
Then  quickly  follow  a  wild  throbbing 
of  the  arteries  of  the  neck  and  palpita- 
tion of  the  heart.  The  pulse  never  ex- 
ceeds 110.  The  inebriate  wishes  to  be 
left  alone;  he  will  not  speak  lest  saliva 
escape  from  the  mouth.  The  ears  be- 
come hot,  the  cheeks  pale,  the  nose 
pinched  and  cold.  The  height  of  intoxi- 
cation is  marked  by  coldness  of  the 
finger-tips  and  dilatation  of  the  pupils. 
This  stage  lasts  from  thirty  to  forty- 
five  minutes,  when  the  victim  longs  for 
a  fresh  dose. 

The  teeth  and  tongue  of  old  habitufs 
turn  absolutely  black.  The  craving  for 
an  increased  dose  is  pronounced.  In  one 
case  it  was  so  marked  as  to  cause  a 
jump  from  1  to  20  grains  in  a  month. 
The  worst  sequel®  are  very  obstinate 
forms  of  diarrhoea  and  dyspepsia.  Of 
the  mental  derangements,  hallucinations, 
and  delusions  causing  dejection  and  fear, 
are  common.  A  more  miserable  object 
than  a  confirmed  Hindoo  cocaine-eater 
cannot  be  pictured.  The  drug  is  alto- 
gether more  disastrous  in  its  effects 
than  is  opium  or  any  other  narcotic 
used  in  India.  To  quote  the  words  of 
a  victim,  "To  eat  cocaine  is  to  court 
misery."  Kailas  Chunder  Bose  (Brit. 
Med.  Jour.,  AprU  26,  1902). 

I  have  not  seen  insomnia  incite  to 
cocainomania  as  it  frequently  does  to 
morphinomania.  Physical  pain  has  been 
the  initial  starting-point.  The  use,  for 
any  purpose,  of  cocaine  is  an  unmistak- 
able influence  inciting  to  the  "cocaine 
habit"  in  constitutions  predisposed  to 
narcotic  excitation.  Other  narcotic  sub- 
stances also  both  predispose  and  ex- 
cite to  the  cocaine  mania.  Jlorphine,  for 
example,  long  continued  is  apt  to  create 
a  crave  or  impulse  too  imperious  to  be 
satisfied  with  morphine  narcotism  alone. 
Case  of  mixed  addiction,  morphine  and 
cocaine,  the  habit  for  the  latter  drug 
having  been   acquired  by  its  use  as  a 


260 


COCAINOMANIA.    PATHOLOGY. 


substitute  for  the  former,  with  the  usual 
disastrous  results,  namely:    loss  of  ap- 
petite and  sleep,  vertigo,   syncopal  and 
epileptiform  attacks,  and,  finally,  hallu- 
cinations  and   delusions,   ideas    of   sus- 
picion, jealousy,   and   persecution ;    also 
hallucinations    of    animalcules    on    the 
skin,  which  are  so  characteristic  of  the 
action   of   cocaine.     Cocaine   is   a   toxic 
agent  far  more  formidable  than  morphine 
on  account  of  the  rapidity  and  intensity 
with  which  the  sensory,  motor,  and  in- 
tellectual   derangements    develop    under 
its  use.     Warning  against  employing  it 
as  a  substitute  for  morphine  with  those 
addicted  to  the  latter  drug.    Laury  (La 
Sera.  M6d.,  Aug.  10,  '90). 
In  inorphinomaniacs  cocaine  is  some- 
times resorted  to  simply  with  the  object 
of  heightening  the  pleasurable  sensations 
of  intoxication.    In  not  a  few  instances 
cocaine  addiction  has  been  rapidly  set 
up  in  the  vain  attempt  to  cure  alcoholo- 
mania or  morphinomania  by  substituting 
cocaine.     This  attempt  at  the  cure  of 
the    original    form    of    narcomania    (a 
mania  for  narcotism  by  any  narcotic)  is 
sometimes   openly   attempted    with   the 
best  intentions;    but  is  more  often  un- 
knowingly tried  simply  because  cocaine 
has  been  a  component  of  the  so-called 
"cure,"    though    not    disclosed    by   the 
manufacturers.     In  this  way  even  some 
abstainers   from    alcoholic    liquors   who 
pride  themselves  on  their  consistent  tem- 
perance have  insensibly  become  cocaine 
slaves,  they  having  had  no  idea  that  they 
and   theirs   were   partaking   of   a   nar- 
cotic poison  more  fascinating  and  peril- 
ous than  the  object  of  their  aversion: 
alcoholic  intoxicants.    A  striking  object- 
lesson  of  medical  unwisdom  was  the  ap- 
pearance of  a  crop  of  cocainomaniacs  in 
England    shortly    after    the   announce- 
ment, in  a  British  medical  annual,  of  the 
reputed  cure  of  alcoholomania  and  mor- 
phinomania  by   means   of   cocaine,    in 
another  country. 

Below  sixteen  years  of  age  there  would 


appear  to  be  a  lessened  susceptibility  as 
the  years  go  down,  children  showing  less 
cocainomaniacal  proclivities  than  adults, 
and  not  responding  so  readily  to  the 
narcotic  properties  of  the  drug  in  doses 
relatively  corresponding  to  their  years. 
Though  the  young  are  readily  intox- 
icated by  cocaine,  they  are  not  so  prone 
to  become  subject  to  the  mania  for  in- 
toxication by  cocaine. 

As  to  sex,  the  majority  of  the  cases 
have  been  male;  but  this  has  not  arisen 
because  of  a  lesser  susceptibility  that  is 
found  in  man,  but  probably  is  owed 
to  occupation  exercising  a  stronger  in- 
fluence. 

Occupation  is  a  predominant  factor, 
most  of  the  victims  having  been  medical 
men  (I  have  seen  a  number  of  eases  in 
members  of  the  legal  profession),  literary 
men  and  women,  and  the  cultured  gen- 
erally. 

Climate  exercises  considerable  influ- 
ence, which  may  account  for  the  greater 
prevalence  of  cocainomania  in  the 
United  States  of  America  and  northern 
France,  as  compared  to  Great  Britain. 
Racial  characteristics  and  atmospheric 
conditions  modify  purely  climatic  en- 
vironment, however;  witness  the  prac- 
tical absence  of  cocainomania  among  the 
great  community  of  the  Jews,  and  the 
rapid  electrical  disturbances,  as  well  as 
the  tremendous  temperature  alterations, 
of  North  America. 

The  cocaine  inheritance  has  not  had 
time  to  show  itself,  if  it  exist;  but  the 
"cocaine  habit"  as  an  outcome  of  trans- 
formed narcomaniac  transmission  I  have 
seen  in  several  families. 

Pathology.  —  Acute  Cocainism. — 
Tliou^^^h  a  large  number  of  cases  of  acute 
cocaine  poisoning  have  been  recorded 
by  Germain  S6e,  Mattison,  Schede,  and 
others,  comparatively  few  have  proved 
fatal.     Probably  the  fatalities  have  run 


COCAINOJIANIA.    PROGNOSIS. 


261 


not  much  over  10  per  cent.  Even  in 
exceedingly  grave  cases,  when  the  suf- 
ferer appears  almost  moribund,  the  dis- 
tress and  collapse  often  suddenly  and 
unexpectedly  give  way  and  the  appar- 
ently dying  patient  makes  a  good  recov- 
ery. Hence  there  has  been  little  op- 
portunity for  post-mortem  inspection. 
Clifford  Allbutt  says  that  the  heart  is 
found  in  diastole  and  the  nervous  cen- 
tres are  congested.  According  to  Ehr- 
lich,  vacuolary  degeneration  is  found  in 
the  hepatic  cells,  the  latter  being  greatly 
enlarged  and  the  nuclei  atrophied. 
The  convulsive  respiratory  paralysis  is 
ascribed  by  Mosso  to  tetanus  of  the 
respiratory  muscles,  and  the  great  rapid- 
ity of  the  circulation  to  paralysis  of  the 
vagus.  The  peripheral  blood-vessels  are 
contracted.  Cocaine  is  stated  to  alter 
and  injure  the  leucocytes;  Maurel  and 
Beaumont  Small  state  that  these  become 
spherical  and  rigid,  with  increase  of  size. 
They  seem  also  to  have  a  tendency  to 
locate  next  to  the  vessel-wall. 

Death  may  supervene  at  an  early  stage 
from  syncope,  or  at  a  later  from  as- 
phyxia. Cocaine  acts  on  the  central 
nervous  system,  first  exciting  and  after- 
ward paralyzing  this.  Doubts  have  been 
expressed  as  to  whether  the  ansBsthesia 
produced  by  cocaine  is  due  to  the  vaso- 
motor disturbance  or  whether  the  drug 
directly  paralyzed  the  nerve-termina- 
tions. Brown-Scquard  believes  the 
latter,  holding  that  cocaine  acts  through 
the  peripheral  nerves  on  the  nerve-cen- 
tres, which  reacts  in  inhibiting  sensi- 
bility. I  am  inclined  to  think  that  the 
central  nerve-centres  are  affected  in 
both  ways:  by  vasomotor  paralysis  and 
by  peripheral  excitation. 

CnnoNic  CocAiNisjt,  IxcLunixo  the 
Mania  for  Cocatxe.  —  A  distinction 
ought  to  be  made  between  the  physical 
poisoning  by  the  drug  (cocainism),  and 


the  overpowering  mania  for  the  drug 
(cocainomania,  or  the  "cocaine  habit"). 
Of  the  pathology  of  the  latter  little  can 
be  said  specifically.  Usually  scavenger 
or  spider-  cells  are  found  in  the  brain; 
but  as  most  cocaine  hahilues  have  pre- 
viously been  indulgers  in  alcohol,  no 
reliance  can  as  yet  be  placed  on  these  ap- 
pearances as  pathognomonic  of  cocaine 
mania.  Marasmus,  with  absence  of  fat, 
is  usually  the  most  prominent  after- 
death  appearance,  and  there  has  not 
been  noted  the  darkish  hue  of  the 
stomach's  interior  which  has  been  seen 
in  some  cases  of  fatal  opiomania.  The 
post-mortem  appearances  include  dark 
and  fluid  blood,  with  congestion  of  lungs 
and  other  organs,  but  these  are  not 
peculiar  to  cocaine  poisoning.  There 
have  not  been  observed  traces  of  cocaine 
tissue-degradation,  and  organic  degrada- 
tion which  axe  so  often  met  with  in  the 
stomach,  liver,  kidneys,  and  other  vital 
organs  of  alcoholic  cases,  unless  when 
chronic  alcohol  poisoning  has  preceded 
or  accompanied  the  cocaine  indulgence. 
When  cocaine  is  contemporaneous  with 
chronic  morphine  poisoning  the  wasting 
is  even  more  marked.  Though  the 
minimum  fatal  dose  in  acute  cocaine 
poisoning  is  not  quite  fixed,  death  has 
been  recorded  as  the  result  of  less  than 
half  a  grain,  and  several  deaths  have 
occurred  after  8  to  12  grains;  yet  the 
habitue  can  set  up  such  a  tolerance  of 
the  drug  as  to  raise  the  daily  consump- 
tion to  some  30  or  40  grains.  In  some 
instances  the  daily  average  has  been 
more  than  double  this.  In  one  case  80 
grains  a  day  were  subcutaneously  in- 
jected, besides  60  grains  of  morphine. 
One  death  occurred  in  20  minutes,  1  in 
4  minutes,  and  a  third  in  40  seconds 
(Hamilton  and  Godwin). 

Prognosis.  —  The  prognosis  of  acuU 
cocaine  poisoning  is,  on  the  whole,  favor- 


262 


COCAINOMANIA.    TREAT:MEXT. 


able.  Even  though  death  almost  alwaj's 
Beems  impending  from  the  gravity  of 
the  symptoms,  the  great  majority  of 
cases  recover  if  judiciously  treated  soon 
after  the  poisonous  dose  has  been  taken. 
Generally,  after  three-fourths  of  an  hour 
have  passed,  the  prognosis  is  even  more 
favorable.  This  cannot  so  unreservedly 
be  said  of  chronic  cocaine  poisoning 
(the  cocaine  habit,  or  cocainomania),  of 
which  the  outlook  is,  under  ordinary 
conditions,  unfavorable.  If,  however, 
the  patient  siirrender  his  liberty  and 
place  himself  absolutely  under  control 
in  a  special  home  or  in  a  hospital  for  a 
sufficiently  long  period,  the  prognosis 
may  fairly  be  considered  to  be  more 
favorable.  The  prognosis  of  cocaino- 
mania is  not  nearly  so  favorable  as  that 
of  alcoholomania  or  even  morphino- 
mania.  Cocaine  exhausts  the  mental 
capacity  more  rapidly  than  either  mor- 
phine or  alcohol;  it  takes  a  greater  hold 
on  the  brain  and  nervous  system,  reduc- 
ing his  intelligence  and  benumbing  his 
faculties,  setting  up  a  moral  palsy  which 
seems  to  annihilate  inhibition  and  to 
deprive  the  victim  of  all  desire  for  deliv- 
erance. There  are,  however,  exceptional 
cases  which  exhibit  a  strong  wish  to  be 
cured,  which  are  hopeful  and  have  been 
delivered  under  treatment  at  home. 

Treatment. — Acute  Cocaine  Poison- 
ing.— If  the  poison  has  been  swallowed 
the  stomach  syphon-tube  should  be  at 
once  applied  and  the  contents  of  the 
organ  evacuated.  The  patient  should  be 
placed  in  the  horizontal  position  on  his 
back.  Tannic  acid,  iodine,  or  charcoal 
may  be  given  as  possible  chemical  anti- 
dotes. Stallard  advises  the  stimulation 
of  respiration  and  circulation  by  flicking 
the  chest  and  face  with  hot  and  cold 
towele,  as  in  opium  poisoning;  but  I 
cannot  say  that  I  have  seen  benefit  from 
this  practice  unless  it  has  been  done 


lightly  and  occasionally  for  a  minute  or 
two.  Ammonia  or  ether  inhaled,  drunk 
by  the  mouth,  or  introduced  into  the 
rectum,  or  administered  hypodermically, 
is  useful,  as  also  is  the  administration 
of  caffeine  or  coffee.  The  addition  of 
small  quantities  of  alcohol,  in  the  form 
of  5-  to  10-  drop  doses  of  tincture  car- 
damom, comp.,  spirit  of  chloroform,  or 
tincturiB  lavandulaj  comp.  (separate  or 
combined),  is  sometimes  serviceable  when 
coffee  cannot  be  easily  taken.  Chloro- 
form may  be  inhaled  to  relieve  the 
spasm.  Strychnine,  in  minute  doses 
(^Aoo  grain),  with  or  without  a  couple 
of  drops  or  so  of  tincture  of  digitalis,  is 
also  of  value.  Some  authors  report  ap- 
parent benefit  from  intravenous  injec- 
tion of  normal  saline  solution;  but  I 
think  caution  is  requisite,  owing  to  the 
risk  of  embolism  in  the  lungs. 

When  the  blood-pressure  has  been 
raised  or  there  is  alarming  respiratory 
spasm,  a  drop-dose  of  nitroglycerin,  at 
intervals  of  half  an  hour  if  required, 
sometimes  acts  excellently.  Clifford  All- 
butt  says  that  the  inhalation  of  oxygen 
and  artificial  respiration  against  the  as- 
phyxia may  be  indicated.  I  have  found 
sips  of  hot  water;  and,  where  this  could 
not  be  taken  by  the  mouth  on  account 
of  insensibility  or  collapse,  hot-water 
enemata,  of  3  to  4  ounces,  of  substantial 
aid.  External  applications,  as  hot  as 
can  be  borne,  such  as  a  bottle,  or  jar,  or 
tin  filled  with  hot  water  and  covered 
with  flannel  to  protect  tlie  skin,  I  make 
it  a  rule  always  to  apply,  especially  in 
unconsciousness,  and,  indeed,  almost 
from  tlie  first. 

CnnoNic  Cocaine  Poisoning,  or 
Cocainomania. — The  treatment  of  the 
cocaine  habit,  or  chronic  cocaine  intoxi- 
cation, is  very  much  more  diflicult.  It  is 
more  essential  to  have  complete  control 
of  the   cocainomaniac  and   his  actions 


COCAINOMANIA.    TREATMENT. 


263 


than  even  in  chronic  alcohol  or  mor- 
phine mania.  There  is  less  to  work 
upon  in  the  brain-  and  nerve-  centres 
of  the  chronic  cocainist  than  in  those 
of  the  chronic  alcoholist  or  chronic  mor- 
phinist. There  is  less  mental  and  moral 
elasticity,  less  desire  to  be  freed  from 
the  narcotic  bondage,  less  consciousness 
of  the  bondage  itself,  a  more  helpless  and 
hopeless  wreck  being  difficult  to  find. 
Cocainomaniacs,  however,  are,  in  a  few 
cases,  cured  without  seclusion.  In  these 
hopeful  cases  there  generally  has  been  a 
greater  stock  of  inhibition  from  the  first. 
Again,  the  indulgence  having  been  peri- 
odical and  ordinarily  provoked  only  by 
some  recurrent  neurotic  pain  or  distress 
and  leaving  intervals  of  shorter  or  longer 
non-narcotic  consumption  between,  in- 
hibition has  not  been  so  paralyzed,  and 
thus  there  has  been  more  resisting  power 
left.  In  the  latter  group  of  cases  it  is 
imperative  to  direct  the  treatment  to  the 
abolition  or  counteraction  of  the  exciting 
influences. 

In  the  mass  of  cases  the  main  hope 
of  cure  rests  in  therapeutic  seclusion. 
The  patient  must  be  treated  as  a  dis- 
eased person.  Diet,  at  first  simple  and 
readily  assimilable,  should  be  carefully 
attended  to.  Milk,  with  soda-  or  lime- 
water  and  effervescents  if  nausea  and 
emesis  are  present;  arrowroot  or  other 
farinaceous  or  malted  food,  and  other 
peptonized  preparations  are  excellent. 
Gradually,  broths  and  plain  soups,  oys- 
sters,  fish,  poultry,  and,  lastly,  mutton 
and  red  meat,  with  an  ample  supply  of 
fruit  and  vegetables,  may  be  given.  But 
there  are  cases  in  which  a  non-fish-and- 
flesh  dietary  agrees  better  with  the  pa- 
tient. Each  case  mxist  bo  carefully  ob- 
served to  determine  the  most  suitable 
dietetic  instructions. 

In  the  first  week  exercise  and  fresh 
air   may   usually   be    insisted    on,    with 


massage  to  improve  the  wasted  condition 
of  the  muscles.  Meals  should  be  regular, 
and  exercise  graduated. 

Alcoholic  beverages  are  best  avoided; 
and,  though  in  a  few  cases  tobacco  in 
limited  quantities  may  be  allowed  to  aid 
in  staying  the  morbid  impulse  or  crave, 
most  cocainomaniacs  would  be  better 
without  it  in  any  form.  Tobacco  is  apt, 
in  many  patients,  to  impair  digestion 
and  depress  the  heart's  action,  the 
healthy  state  of  both  vital  processes 
being  points  of  the  highest  importance 
in  the  treatment  of  this  mania. 

To  combat  the  wearing  insomnia  of 
most  cases  I  know  nothing  better  than 
the  hot,  wet  pack.  Of  all  the  medicinal 
hypnotics,  I  have  found  phenacetin  the 
most  useful,  in  doses  of  5  grains,  re- 
peated, if  necessary,  every  hour;  no 
more  than  3  doses  (15  grains)  to  be 
taken  in  one  night.  Other  physicians 
have  found  chloral  and  sulphonal  serv- 
iceable. 

An  important  practical  point  is  the 
method  of  complete  withdrawal  of  the 
cocaine,  which  complete  withdrawal  is 
essential  to  cure.  In  most  cases  I  have 
not  felt  justified  in  immediate  with- 
drawal, though  I  have  done  this  where 
practicable.  I  spread  the  reduction 
period  over  from  seven  to  nine  days,  be- 
ginning, whatever  the  quantity  which 
had  been  taken  daily  or  how  long,  with 
a  reduction  of  one-half.  Dr.  Welch 
Branthwaite  informs  me  that  in  five 
cases  he  at  once,  after  only  one  dose, 
stopped  the  cocaine,  without  trouble. 
These  were  cases  in  which  morphine 
had  also  been  freely  used.  In  the  cases 
in  which  I  gradually  reduced  the  dose 
of  cocaine,  morphine  had  not  been 
habitually  taken  in  large  doses.  Where 
morphine  is  also  freely  and  regularly 
taken,  it  is  easier  to  withhold  the  cocaine 
without  delay. 


264 


COCAIXOJIANIA. 


COFFEE  AND  CAFFEINE. 


The  sudden  removal  of  the  drug  is  the 
first  step,  with  sharp  elimination  through 
the  skin,  kidneys,  and  bowels.  The  con- 
tinuous activity  of  the  skin  from  hot  air, 
sweating,  and  baths  is  essential,  and  this 
should  be  kept  up  for  a  long  time.  Nar- 
cotics are  dangerous  and  are  seldom  of 
any  value.  Infusion  of  einohona-bark  is 
very  valuable,  and  can  be  used  for  a 
long  time.  Arsenic  appears  to  be  the  best 
of  all  the  mineral  tonics,  and  acids  are 
also  excellent. 

Among  foods,  meats  are  to  be  used 
sparingly  at  first.  The  patient  should 
remain  in  bed,  reclining  at  full  length 
most  of  the  time  during  active  treatment. 
Muscular  exercise  by  massage  for  an 
liour  a  day  should  be  given,  or  a  walk 
in  the  open  air  with  an  attendant  or  a 
few  moments'  exercise  with  ropes  and 
pulleys.  Daily  baths  should  be  continued 
with  regularity  and  care.  Persistent 
watchfulness  over  all  acts  of  the  patient 
should  be  kept  up  for  6  or  8  weeks;  then 
a  rigid  course  of  living  and  diet  arranged, 
and  its  importance  insisted  upon,  for  a 
long  period  to  come.  T.  D.  Crothers 
(Phila.  Med.  Jour.,  May  2S,  '98). 

All  complications  must  be  attacked, 
but,  in  the  main,  besides  hygienic  meas- 
ures, nervine  tonics  are  indicated  in  the 
endeavor  to  restore  the  lost  energy  and 
will-power  which  really  constitute  the 
disease.  Of  these  tonics  nux  vomica  and 
strychnine  are  the  most  effectual.  Ar- 
senic also  is  useful.  I  have  found  in 
this,  as  in  other  forms  of  narcomania, 
that  an  occasional  replacement  of  the 
stronger  nerve-tonics  by  milder  ones  is 
advantageous;  I  mean  such  as  quinine, 
calumba,  and  gentian.  Galvanism  has, 
in  appropriate  cases,  its  value. 

Though  it  is  often  asserted  that  3  to 
6  months  sulTice  to  efFect  a  cure,  my  ob- 
servation has  been  that  12  months  con- 
stitute the  shortest  time  in  which  such 
a  result  can  be  hoped  for.  There  are,  at 
the  same  time,  a  few  exceptional  cases 
in  which  a  good  result  has  been  secured 
in  a  shorter  period. 


Medico-legal  Relations. — As  many  co- 
cainists  will  not  apply  for  curative  de- 
tention of  their  own  accord,  it  ought  to 
be  the  duty  of  the  constitutional  author- 
ities to  lay  hold  on  these  miserable  and 
utterly  helpless  diseased  persons,  and  in- 
sist on  their  reception  and  therapeutic 
seclusion  for  a  given  time,  in  a  retreat, 
home,  or  hospital  provided  for  the  spe- 
cial treatment  of  such  cases,  with  pro- 
vision for  persons  with  limited  resources 
and  for  the  very  poorest.  Such  a  pro- 
vision would,  in  the  long  run,  prove  as 
economical  as  it  would  be  invaluable  to 
the  welfare,  physical  and  moral,  of  the 
whole  community. 

I  am  unaware  of  any  trial  for  murder 
or  for  administering  cocaine  with  intent 
to  injure  another  person;  but  cocaine 
has  been  employed  to  commit  suicide. 
It  has  been  stated  recently  that  forty 
cocainomaniacs  appeared  in  the  police- 
courts  of  Chicago  within  the  period  of  a 
few  months  in  1897.  The  habit  was  said 
to  have  been  induced,  in  some  cases,  by 
the  use  of  popular  preparations  as  cures 
for  colds,  etc.  In  the  charters  of  various 
special  institutions  in  the  United  States 
power  is  given  to  the  managers  to  re- 
ceive and  compulsorily  detain  habitual 
inebriates  who  are  addicted  to  excess  in 
any  narcotic  or  inebriant,  including  co- 
caine; but,  in  England,  only  excess  in 
alcoholic  liquors  renders  applicants  eligi- 
ble for  admission  into  retreats  under  the 
voluntary  provisions  of  the  Inebriates' 
Acts. 

NouMAK  Kerr  (London)   and 
Central  Staff  (Pliilndolpliia). 

COFFEE  AND  CAFFEINE.  —  The 
seeds  or  berries  of  Cafjea  Arahica,  so 
extensively  employed  for  the  prepara- 
tion of  the  beverage,  are  not  olTicially 
recognized  except  as  the  main  source  of 
caffeine.     A   fluid   extract  of  the  green 


COFFEE.    PHYSIOLOGICAL  ACTION.    POISONING. 


265 


berry  was  formerly  employed  as  a  stimu- 
lant, however,  and  the  infusion  is  now 
considerably  used  for  the  same  purpose 
in  the  treatment  of  shock,  poisoning,  etc. 

Before  it  is  roasted  coffee  contains  caf- 
feine, caffeotannic  acid,  and — accord- 
ing to  Palladine — an  alkaloid:  caffea- 
rine.  During  the  roasting  process,  how- 
ever, a  volatile  oil  is  developed,  which, 
with  the  other  substances,  termed,  col- 
lectively, "caffeone,"  give  the  coffee  its 
agreeable  aroma. 

Administration  and  Dose. — The  infu- 
sion affects  its  users  in  different  ways, 
some  tolerating  large  quantities,  others 
feeling  the  influence  of  one-half  cupful. 
There  is,  therefore,  no  special  dose  to  be 
recommended.. 

The  fluid  extract  of  green  coffee  may 
be  given  in  doses  varying  from  1  to  2 
drachms. 

Physiological  Action.  - —  Marshall  and 
Hare  have  studied  the  action  of  the  em- 
pyreumatic  oil  of  coffee.  The  percentage 
of  oil  obtained  from  an  average  browned 
coffee  is  11.6  per  cent.;  in  consequence, 
an  ordinary  breakfastcup  of  coffee  con- 
tains about  45  minims  of  the  oil,  pro- 
vided all  the  oil  in  the  coffee  used  is 
extracted.  In  their  opinion,  the  oil  pos- 
sesses none  of  the  powers  of  a  toxic  char- 
acter heretofore  supposed.  The  pure  oil 
increases  the  pulse-rate  by  direct  car- 
diac stimulation  in  small  doses,  and  low- 
ers pulse-rate  in  large  doses  by  a  direct 
depressant  effect  on  this  viscus.  On  the 
highly-developed  spinal  cord  of  the  frog 
it  causes  increased  reflex  activity;  but, 
on  the  mammal  with  a  well-developed 
brain,  drowsiness  and  sleep. 

The  virtues  of  coffee,  in  the  wear  and 
tear  of  active  life,  are  entirely  subjective, 
and  depend  upon  a  general  excitation  of 
the  higher  centres,  and  chiefly  upon  its 
powerful  exhilarant  action  upon  the  men- 
tal processes.    It  must  be  said,  however, 


that  the  assumed  ability  of  coffee  to  re- 
place food,  or  to  increase  the  power  for 
work  without  corresponding  tissue-de- 
struction, is  deceptive.  While  a  moder- 
ate consumer  of  coffee  may  be  assisted  by 
the  stimulating  action  of  the  beverage, 
an  intemperate  consumer  may  be  capa- 
ble of  performing  prodigious  feats  of 
strength  and  endurance,  but,  neverthe- 
less, at  the  direct  expense  of  his  tissues. 

Prosorowsky  studied  the  influence  of 
coffee  and  some  of  its  substitutes  upon 
pathogenic  micro-organisms,  and  con- 
cluded that  coffee  possessed  incontest- 
able antiseptic  properties;  in  this  respect 
it  is  superior  to  both  its  substitutes,  rye 
and  acorn  coffee,  the  acorn  being  the 
more  active  of  the  two  latter.  The  anti- 
septic action  is  due  to  the  empyreumatic 
substances  formed  during  roasting,  and 
also  partly  to  caffeotannic  acids,  the  pres- 
ence of  which  is  alone  capable  of  explain- 
ing the  antiseptic  action  sometimes 
shown  by  infusions  of  raw  ground  coffee. 
A  cup  of  coffee  left  in  a  room  remains 
free  from  bacteria  for  over  a  week. 

Poisoning  by  Coffee. — Eugh  witnessed 
a  case  in  which  profound  toxic  effects 
from  the  drinking  of  large  quantities  of 
strong  coffee  were  observed,  a  number 
of  symptoms  being  those  of  beginning 
mania  a  potu.  The  patient's  pulse  was 
06  and  full,  but  weak;  his  respirations 
shallow  and  niimbering  24  to  the  minute. 
The  pupils  were  normal,  the  tongue 
slightly  coated,  the  bowels  regular;  the 
skin  moist,  but  not  flushed;  his  expres- 
sion was  agitated  with  the  fear  of  some 
impending  danger.  His  muscles  were  in 
such  a  state  of  tension  that,  upon  the 
slightest  movement  of  arms  or  legs,  clonic 
spasms  occurred,  though  none  was  pres- 
ent when  he  lay  perfectly  relaxed,  which, 
however,  his  exceedingly-nervous  condi- 
tion would  not  allow  him  to  do.  If  he 
tried  to  sleep,  he  would  be  seized  with 


266 


COFFEE.    THEKAPEUTICS.     CAFFEINE.    PHYSIOLOGICAL  ACTION. 


hallueinations  just  before  losing  con- 
sciousness, imagining  that  disasters  were 
about  to  overtake  him  and  seeing  all 
kinds  and  shapes  of  images  and  objects. 
Then  he  would  start  up  with  fright  and 
find  himself  in  the  greatest  nervous  ex- 
citement. WTien  he  stood  up,  he  could 
close  his  eyes  or  look  at  the  ceiling 
without  wavering.  His  knee-jerks  were 
slightly  exaggerated,  but  sensation  was 
perfect. 

Case  in  which  2  cupfuls  of  an  infusion 
made  of  2  handfuls  of  coffee  produced 
intense  general  tremors,  lasting,  in  spite 
of  bromide  treatment,  twelve  hours  after 
all  other  symptoms  had  disappeared. 
Cohn  (Therap.  Monats.,  Mar.,  '89). 

Therapeutics. — Coffee  infusion  is  a 
most  valuable  stimulant  for  cases  of  nar- 
cotic poisoning,  opium,  belladonna,  chlo- 
ral, etc.  "^^Hiile  it  may  prove  effective 
when  administered  by  the  mouth,  it  acts 
with  far  greater  rapidity  when  adminis- 
tered by  rectal  injection.  It  may  be 
given  ad  libitum  in  such  cases,  and  its 
effects  will  appear  sooner  in  proportion 
as  the  infusion  is  strong. 

The  rapidity  of  absorption  is  enhanced 
if  the  temperature  of  the  infusion  ap- 
proximates that  of  the  intestine  (100° 
F.),  since  cold  or  heat  produce  moment- 
ary shock  from  which  the  intestinal  walls 
must  recover  before  the  absorption  can 
begin.    (Sajous.) 

In  the  collapse  of  ana3sthesia,  the  toxic 
effects  of  venomous  stings  and  bites,  it  is 
an  invaluable  adjuvant  when  employed 
by  rectal  injection.  It  sustains  all  the 
vital  functions  while  the  poison  is  exert- 
ing its  cfTects,  and  carries  the  patient 
throufrh  the  ordeal. 

Caffeine. 

Caffeine  should  be  obtained  from 
the  dried  seeds  of  coffee,  but  the  caf- 
feine of  the  drug-stores  is  really  thcine, 
since  it  is  cheaper  to  manufacture  the 
alkaloid  from  damaged  tea  than  coffee. 


It  occurs  as  long,  fleecy  crystals,  silky  in 
appearance,  having  no  particular  odor 
and  bitter  to  the  taste.  It  is  soluble  in 
SO  parts  of  water  and  fixed  proportions  of 
ether,  chloroform,  and  very  soluble  in 
boiling  water.  Caffeine  is  closely  allied 
to  theobromine,  found  in  cacao,  coca, 
and  other  plants. 

Administration  and  Dose.  —  Citrated 
caffeine  is  frequently  employed,  owing  to 
its  greater  solubility;  but,  Tanret  hav- 
ing sho\^Ti  that  the  addition  of  equal 
proportions  of  the  benzoate  or  salicylate 
of  sodium  caused  a  marked  increase  of 
solubility,  this  mode  of  prescribing  the 
drug  is  now  often  used. 

A  pleasant  preparation  is  the  efferves- 
cent citrated  caffeine  (U.  S.  P.),  made 
by  "triturating  together  10  parts  each  of 
caffeine  and  citric  acid,  330  of  sodium 
bicarbonate,  300  of  tartaric  acid,  and  350 
of  sugar,  making  the  powder  into  a  paste 
with  enough  alcohol  to  make  1000  parts, 
passing  the  paste  through  a  No.  6  sieve, 
drying  it,  and  reducing  it  to  a  coarse 
powder.  It  must  be  kept  in  well-stop- 
pered bottles."  The  dose  is  from  1  to  3 
drachms. 

Physiological  Action. — Cohnstein  has 
formulated  the  following  conclusions, 
which  agree  with  those  of  most  observers: 
1.  In  small  doses  caffeine  produces  an 
increase  of  the  arterial  pressure,  while 
larger  amounts  prevent  this  increase.  2. 
The  influence  upon  the  blood-pressure 
is  the  result  of  the  changed  condition 
of  irritability  of  the  vasomotor  centre, 
caused  by  the  caffeine.  3.  Caffeine  has 
a  direct  action  on  the  heart,  showing 
itself  in  the  pulse-frequency  and  wave- 
height,  first  as  an  irritation  and  then  as  a 
paralysis.  4.  The  heart-muscle  is  af- 
fected by  caffeine  in  precisely  the  same 
manner  as  the  skeletal  muscle. 

As  to  the  effects  of  caffeine  on  blood- 
pressure,  Gaetano  Vinci  found  that  in 


COFFEE.    CAFFEINE.    POISONING. 


267 


all  cases  there  was  a  rise  of  blood-press- 
ure, whether  the  drug  was  administered 
by  the  mouth,  intravenously,  or  hypo- 
dermically,  with  a  consequent  fall  of 
pressure  only  in  rabbits.  In  dogs  and 
rabbits  subjected  to  repeated  blood-let- 
tings, there  was  a  constant  rise  to  the 
normal,  and  often  far  above.  In  dogs 
suffering  from  inanition  there  was  a  con- 
stant elevation  of  blood-pressure  propor- 
tionate to  the  weakness  of  the  animal, 
except  in  cases  where  the  lowering  of 
vital  forces  had  gone  so  far  as  to  affect 
the  heart-muscle. 

Schneider  found  that  after  therapeutic 
doses  caffeine  could  not  be  detected  in 
the  urine  of  cats  or  men,  but  that  after 
comparatively-large  doses  it  was  readily 
obtained.     Contrary  to  the  opinion  of 
Maly  and  Andreasch,  he  thought  that  the 
greater  part  of  the  drug  was  destroyed 
in  the  body.     The  discrepancy  in  the 
results  of  these  various  investigators  may 
have  been  due,  according  to  C.  K.  Mar- 
ehall,  to  differences  in  the  dose  adminis- 
tered, the  animal  iised,  or  the  methods 
of  estimation  of  the  alkaloid  employed. 
Caffeine  acts  chiefly  as  a  stimulant  to 
the  nervous  system.     In  this  manner  it 
affects  the  action  of  the  heart,  causing 
the   beats   to    become   stronger,   and    in 
some   cases   more   rhythmical ;    but,   un- 
like digitalis  and  strophanthus,  it  has 
no     specific    action     on    the   inhibitory 
nerves  of  that  organ.     Its  action  on  the 
vasomotor  centres    is    marked,    causing 
contraction  of  the  vessels  and  increased 
tension  in  the  same,  the  blood-pressure 
rising.    Pawinski  (Zeitsch.  i.  klin.  Med., 
B.  23,  H.  5,  C,  '94). 

Caffeine  facilitates  muscular  labor  by 
increasing  the  activity  not  of  the  mus- 
cle itself,  but  of  the  corresponding  cere- 
bro-spinal  centre.  As  a  consequence  of 
this  double  action  on  the  cerebrum  and 
medulla,  the  sensation  of  effort  is  dimin- 
ished and  keeps  off  fatigue.  The  drug 
further  prevents  loss  of  breath  and  pal- 
pitation due  to  severe  muscular  effort. 
It  does  not  check  tissue-waste.    Caffeine 


allows  more  exertion  through  a  kind  of 
physiological  economy.    The  drug  would 
seem  to  place  a  person  untrained  in  the 
position  of  one  who  had  been  subjected 
to  perfect  physical  training.     The  inges- 
tion of  food  allows  of  a  certain  amount 
of  exertion,  but  fatigue  comes  on  before 
the  assimilated  products  of  digestion  are 
used    up,    and    thus    a    reserve    is    left. 
Caffeine  seems  to  use  up  more  or  less 
of  that  reserve,  and  hence  the  drug  is 
beneficial    only    temporarily.      Germain 
S6e  and   Lapicque    (Bull,   de   I'Acad.  de 
Med.,  Mar.,  '90). 
Caffeine  is  thought  by  some  observers 
to  be  one  of  the  drugs  instinctively  de- 
sired by  man,  because  of  its  exciting  in- 
fluences.     Caffeine    in    small,    repeated 
doses,  according  to  this  view,  may  be  ad- 
vantageously  prescribed   to   soldiers   on 
the  march,  as  it  increases  muscular  ac- 
tion and  promotes  the  activity  of  the 
motor-nervous  system,  both  cerebral  and 
medullary.     The  result  of  this  double 
action  is  to  diminish  the  sensation  of 
effort  and  to  prevent  fatigue.     It  pre- 
vents shortness  of  breath,  with  resultant 
palpitation.    In  this  manner  it  supplies 
vigor  to  one  who  is  engaged  in  severe 
and  prolonged  exercise. 

Caffeine  and  theobromine  act  as  direct 
excitants  of  the  renal  parenchyma.  In 
contrast  with  the  saline  diuretics,  which 
appear  chiefly  to  provoke  elimination  of 
water  and  at  the  same  time  of  salts, 
and  especially  chlorides,  the  xanthin 
bodies  increase  the  elimination  of 
nitrogenous  elements,  and  specially  urea 
and  uric  acid.  Anten  (Arch.  Inter,  de 
Pharm.  et  de  ThCrap.,  vol.  viii,  fasc.  v 
and  vi,  1001). 

As  far  back  as  1721  coffee  was  con- 
sidered to  "be  excellent  in  the  time  of 
pestilence  and  contributes  greatly  to 
prevent  the  spread  of  infection."  The 
writers  review  the  work  that  has  been 
done  vip  to  the  present  time  in  the 
study  of  the  deodorant  and  antiseptic 
properties  of  coffee,  and  conclude  their 
paper  with  an  account  of  their  own  ex- 
periments in  this  field  of  research.  In- 
fusions of  green  coffee,  they  find,  have 


268 


COFFEE.     CAFFEINE.    THERAPEUTICS. 


no  antibacterial  properties.  Infusions 
of  roasted  coffee  have.  The  latter  are 
able  to  inhibit  putrefaction  and  prevent 
the  growth  of  many  bacteria  even  in 
the  most  suitable  culture  media.  To 
what  coffee  owes  these  qualities  it  is 
at  present  impossible  to  say.  It  is  not 
probable  that  caffeine  plays  any  part  in 
the  action  of  coffee  upon  bacteria. 
Crane  and  Piiedliinder  (Amer.  Med., 
Sept.  5,   1903). 

Poisoning  by  Caffeine. — James  Fergu- 
son observed  a  case  of  tonic  spasm  follow- 
ing a  medicinal  dose  of  citrate  of  caffeine, 
repeated  three  hours  later  for  severe 
headache,  which  became  more  violent 
than  before.  There  was  jerking  of  the 
hands  and  forearms,  the  fingers  began 
to  be  rigidly  clenched,  and  shortly  after 
the  head  was  seen  to  be  drawn  to  one 
side,  with  the  jaws  tightly  fixed  together. 
At  this  stage  the  author  found  the  fingers 
of  both  hands  as  described,  and  the  mus- 
cles of  the  face  tightly  drawn,  but  with 
some  imperfect  articulation  by  this  time 
possible.  Friction  of  the  affected  parts 
did  some  good,  and  a  dose  of  30  grains 
of  chloral  was  ultimately  followed  by 
recovery  of  control  over  the  muscles. 
There  had  been  no  loss  of  consciousness 
throughout.  The  patient's  sensation  had 
been  chiefly  one  of  great  faintness  and 
nausea.  The  author  suggests  that  the 
use  of  the  drug  be  watched,  since  it  has 
become  a  popular  remedy  for  headache. 

Therapeutics. — European  observers — 
Huchard,  Ferrara,  and  others — state  that 
cafTeine,  given  by  the  mouth,  does  not, 
even  in  large  doses,  show  its  best  effects, 
because  it  is  eliminated  with  great  ra- 
pidity. The  hypodermic  method  is  the 
best,  and  is  painless,  producing  no  cuta- 
neous reaction. 

In  diseases  of  the  heart — both  those 
depending  on  degenerative  processes  in 
the  muscular  fibres  and  such  as  are 
termed  functional — the  action  of  caffeine 
is  striking  and  beneficial.    In  these  affec- 


tions the  use  of  digitalis  is  only  indicated 
during  a  later  stage  of  the  disease,  when 
the  heart  is  no  longer  capable  of  fulfill- 
ing its  duties,  when  cedema  and  dyspnoea 
have  set  in.  Caffeine  is  further  of  great 
use  in  attacks  of  dyspnoea,  such  as  are 
observed  in  cases  of  sclerosis  of  the  cor- 
onary arteries,  and  also  in  cardiac  insuffi- 
ciency following  on  overexertion,  severe 
moral  shock,  or  febrile  maladies. 

Dropsy. — In  dropsical  effusions  re- 
sulting not  only  from  heart  affections, 
but  from  disorders  of  other  viscera,  the 
diuretic  properties  of  caffeine  frequently 
manifest  themselves  advantageously. 

In  cardiac  dropsy  digitalis  is  the  most 
useful  drug,  but  when  it  does  not  afford 
relief  caffeine  may  be  of  valuable  serv- 
ice. Case  in  which  the  heart  was  greatly 
enlarged,  and  the  impulse  strongly 
marked,  the  apex-beat  being  in  the  sev- 
enth space  in  the  anterior  axillary  line. 
There  were  signs  also  of  dilatation  of  the 
aorta.  At  the  apex  was  a  loud  and  long 
systolic  murmur.  The  caffeine  was  used 
according  to  the  following  formula: — 

IJ  Caffeines,  5  grains. 
Sodii  salicyl.,  4  grains. 
Aq.,  ad  I  ounce. — M. 

Given  twice  daily,  this  mixture  af- 
forded considerable  relief.  Tickell  (Clin- 
ical Journal,  Feb.  2,  "98). 

In  cardiac  and  renal  disorders  the 
effect  of  caffeine  is  usually  as  follows: 
With  doses  of  3  to  4  'A  grains  two  or 
three  times  a  day,  the  blood-pressure 
rises  steadily,  slowly,  and  the  quantity 
of  urine  is  increased.  CKdoma  is  lessened, 
but  very  slightly.  Botwi'cn  the  fourth 
and  the  sixth  day  the  jjaticnts  begin  to 
complain  of  a  sense  of  constriction  in 
the  chest,  dyspnoea,  and  restless  nights. 
In  some  cases  it  can  be  made  out  by  aus- 
cultatory percussion  that  the  heart  has 
diminished  in  size  in  all  its  diameters; 
this  is  a  sign  of  impending  tetanus  of  the 
cardiac  muscle,  and  the  caffeine  must  be 
at  onco  omitted.  Caffeine  continues  to 
be  excreted  in  the  urine  for  at  least  ten 
to  fifteen  days  after  the  last  dose  is 
taken.      'I'lic    innic    the   kidneys   are   dis- 


COFFEE  AND  CAFFEINE. 


COLCHICUM. 


269 


eased,  the  slower  it  is  excreted  and  the 
greater  is  the  danger.  Caffeine  acts  e.x- 
actly  like  strj'chnine  on  the  spinal  cord, 
the  striated  and  especially  the  cardiac 
muscles.  Zenetz  (Wiener  med.  Woch., 
Dec.  9, '99). 

Febeile  Maladies. — As  a  stimulant 
in  febrile  diseases,  enteric  fever,  pneu- 
monia, scarlatina,  diphtheria,  etc.,  caf- 
feine is  of  great  value.  It  supports  the 
patient's  vital  powers  and  the  cardiac 
action,  and  assists  him  in  resisting  the 
tendency  to  collapse. 

Caffeine  is  very  valuable  as  a  cardiac 
stimulant  in  the  post-febrile  stage  of 
typhoid.  Two  to  4  grains  every  four 
hours  should  be  given.  J.  B.  Walker 
(Annual,  '90). 

The  ad^'namic  state  of  typhoid  fever 
and  pneumonia  is  favorably  influenced 
by  hypodermic  injections  of  caffeine. 
Benzoate  of  soda  is  added  to  the  aqueous 
solutions  of  caffeine,  and  as  much  as  30 
to  45  grains  in  six  to  ten  injections  may 
be  given  daily  without  bad  results. 
Henri  Huchard  (Revue  GCn.  de  Clin,  et 
de  ThCr.,  June  20,  '89). 

In  acute  diseases  of  children  it  ia  to 
be  recommended  as  a  remedy  par  ex- 
cellence, children  supporting  it  better 
than  any  other.  Subcutaneous  injec- 
tions to  administration  by  the  mouth 
prefencd,  G  grains  being  given  daily  in 
two  injections.  Bruneau  (Those  de  Paris, 
Feb.,  '94). 

Beonciiial  Affections. — Caffeine  is 
valuable  in  bronchial  asthma  and  in  bron- 
chitis associated  with  spasm  of  the  bron- 
chial tubes.  When  a  paroxysm  of  asthma 
is  present,  Skerritt  gives  5  grains  of  the 
citrate  of  caffeine  every  four  hours  until 
relief  follows.  When  the  attacks  come 
on  regularly  in  the  early  morning,  a  dose 
of  5  or  10  grains  at  bed-time  often  serves 
to  avert  them.  No  ill  effects  have  fol- 
lowed the  treatment,  even  when  con- 
tinued for  years.  The  drug  sometimes 
causes  slight  wakefulness,  but,  as  a  rule, 
patients  go  to  sleep  without  difficulty 
after  the  nightly  dose  of  5  or  10  grains. 


Cephalalgia. — The  various  forms  of 
headache,  dependent  upon  nervous  ex- 
haustion, and  the  migraine  of  neuro- 
pathic subjects,  are  generally  relieved  by 
effervescent  citrate  of  caffeine.  It  may 
be  advantageously  combined  with  anti- 
pyrine  or  the  bromides. 

COLCHICUM. — Colchicum  auiurnnale, 
or  "meadow-saffron,"  is  a  native  of  Eu- 
rope and  Great  Britain,  and  constitutes 
a  remedy  of  great  repute  abroad,  though 
in  America  it,  of  late  years,  has  fallen 
largely  into  disuse,  not  through  any  lack 
of  intrinsic  therapeutic  worth,  but  be- 
cause of  the  number  of  new  substitutes 
offered.  Indeed,  the  drug  appears  to 
have  passed  entirely  out  of  the  recollec- 
tion of  the  majority  of  teachers,  as  they 
are  so  unfamiliar  therewith  as  to  deny 
it  proper  attention. 

Both  the  bulb  of  the  root  (corm)  and 
seeds  are  employed  medicinally,  and  any 
choice  between  the  two  probably  lies 
with  the  former,  inasmuch  as  it  yields 
more  of  the  alkaloid  colchicine.  The 
corm  is  about  one  inch  long,  ovoid, 
flattish,  with  a  groove  on  one  side, 
wrinkled  and  of  brownish  hue,  internally 
white  and  solid;  inodorous,  with  sweet- 
ish, bitter,  acrid  taste.  It  often  appears 
as  cruciform  transverse  slices  breaking 
with  a  short  mealy  fracture — if  very  dark 
hued,  or  it  breaks  with  a  horny  fracture, 
it  is  inert,  and  consequently  useless.  It 
yields  its  virtues  to  alcohol,  but  not  so 
readily  or  completely  as  to  vinegar  and 
wine. 

The  seeds  are  at  their  best  during  late 
July  and  early  August,  which  is  the 
period  of  collecting.  They  are  nearly 
spherical,  one-eighth  inch  in  diameter, 
of  reddish-brown  hue  externally,  white 
internally,  and  yield  much  the  same 
bitter,  acrid  flavor  as  the  corm. 

Colchicein  is  a  decomposition  product 


270 


COLCHICUM.     PREPARATIONS.     PHYSIOLOGICAL  ACTION. 


of  colchicine,  and  is  had  as  small,  yellow- 
needles;  soluble  in  alcohol,  ether,  and 
chloroform;   slightly  so  in  water. 

Colchicine  appears  both  as  an  amor- 
phous body  and  a  yellow,  crystalline 
powder  melting  at  about  296.5°  F.;  in- 
soluble in  water,  alcohol,  ether,  and 
chloroform;  it  is  very  bitter  and  highly 
toxic. 

Colchicine  tannate  is  a  yellow  powder, 
soluble  in  alcohol  only. 

Preparations  and  Doses. — Colchicum 
abstract  (root,  corm),  1  to  3  grains. 

Colchicum  extract,  fluid  (root),  2  to 
8  minims. 

Colchicum  extract,  fluid  (seed),  3  to  10 
minims. 

Colchicum  extract,  solid  (root),  V2  to 
2  grains. 

Colchicum  extract,  solid  (root),  acetic, 
V2  to  2  grains. 

Colchicum,  powdered  (root),  2  to  6 
grains. 

Colchicum,  powdered  (seed),  3  to  10 
grains. 

Colchicum-syrup,  1  to  4  drachms. 

Colchicum  tincture,  acetated  (root), 
10  to  60  minims. 

Colchicum  tincture  (seed),  10  to  30 
minims. 

Colchicum-wine  (root),  10  to  60 
minims. 

Colchicum-wine  (seeds),  30  to  120 
minims. 

Colchicein,  Viao  to  Vo*  grain. 

Colchicine,  Viso  to  Vao  grain. 

Colchicine  tannate,  V04  to  Vi„  grain. 

Scudamore's  mixture  (carbonate  of 
magnesia,  2  drachms;  Epsom  salt,  8 
drachms;  wine  of  colchicum,  4  drachms; 
peppermint-water,  to  make  12  ounces), 
4  to  8  drachms. 

Larger  doses  of  wine  may  be  em- 
ployed, but  the  drug  then  becomes  very 
actively  piirtralivo  nnd  likewise  emetic. 

Physiological  Action. — In  small  doses 


colchicum  is  a  marked  alterative  and 
cholagogue,  and  further  exercises  some 
mysterious,  but  specific,  action  whereby 
it  becomes  sedative,  and  which  cannot 
be  accounted  for,  save  in  part,  by  its 
evacuant  properties.  It  increases  secre- 
tions generally,  particularly  those  of  the 
liver  and  the  glands  and  mucous  folli- 
cles of  the  intestines.  In  large  doses  it 
purges  copiously,  and  may  likewise  prove 
violently  emetic;  yet  many  people  will 
tolerate  unusual  quantities  without  any 
unpleasant  efliects.  Again,  it  is  not  un- 
common for  colchicum  to  produce  a 
marked  degree  of  exhaustion — perhaps 
even  to  fatality — ere  hypercatharsis  and 
hyperemesis  give  warning  that  it  is  being 
pushed  too  far.  The  stools  produced  by 
the  drug  are  of  a  highly-bilious  char- 
acter, and,  while  at  first  solid  or  semi- 
solid, perhaps  enveloped  with  mucus, 
later  they  are  soft,  liquid,  of  high  color, 
and  may  even  assume  a  dysenteric  char- 
acter. Authorities  are  not  in  accord  as 
to  the  diuretic  powers;  while  some  in- 
sist that  it  favors  solution  and  excretion 
of  uric  acid  and  urea,  others  deny  any 
such  action.  As  a  matter  of  fact,  the 
drug  does  not  always  provoke  diuresis; 
but  this  is  to  be  accounted  for,  perhaps, 
by  the  character  of  the  preparation  em- 
ployed or  the  mode  of  administration. 
Strange  to  say,  alcohol  inhibits  the  ac- 
tion of  colchicum,  yet  the  wine  is  the 
most  active  of  all  the  Galenical  prepara- 
tions. Alkalies  materially  assist  its 
diuretic  and  purgative  properties,  and, 
combined  with  potassium  bicarbonate, 
not  only  is  this  observed,  but  also  the 
antilithic  powers  of  the  latter  are  greatly 
enhanced. 

Colcliicuiri  is  one  of  llie  most  valuable 
ronipdics  in  the  uric-acid  diathesia,  and 
the  prejudice  against  it  is  absurd;  and, 
far  from  it  being  a  vascular  depressant, 
it  often  gives  strength  and  regularil.y  to 
a  feeble  and  irregular  pulse,  especially  in 


COLCHICUM.    PHYSIOLOGICAL  ACTION. 


271 


chronic  gout  with  acute  exacerbations. 
Burney  Yeo  (Brit.  Med.  Jour.,  Jan.  7, 
'88). 

One  of  the  very  good  reasons  why  it 
has  failed  in  many  hands  is  that  it  is 
generally  given  in  purgative  doses,  wliich 
prevents  its  specific  effects  upon  the  cir- 
culation. In  acute  rheumatism  or  gout 
the  circulation  should  be  reduced  with 
aconite  or  veratrum  before  giving  col- 
chicum.  Goss  {"Mat.  Med.,  Phar.,  and 
Special  Ther.,"  '89). 

In  small  therapeutic  doses  produces 
gastro-intcstinal  disturbances,  the  symp- 
toms difl'ering  in  degree  only  from  those 
of  poisoning.  Before  they  come  on, 
however,  there  is  a  lowering  of  the  pulse- 
rate,  sometimes  as  much  as  twelve  beats 
per  minute.  Upon  the  skin  it  acts  oc- 
casionally, producing,  in  some  C£.se3, 
diaphoresis,  and,  it  is  believed,  the 
amount  of  this  action  is  in  inverse  ratio 
to  the  effect  upon  the  bowels.  Any 
nervous  symptoms,  such  as  vertigo, 
headache,  and  muscular  weakness,  which 
may  be  present  as  the  result  of  the 
colchicum,  are  probably  sympathetic 
upon  the  gastro-intestinal  irritation.  It 
is  evident  that  the  dnig  infiuences  the 
bowels  powerfully,  and  probably  in  this 
way  acts  as  an  eliminative.  But,  with 
the  minute  doses  often  used  with  advan- 
tage in  the  disease,  purging  does  not 
occur,  and  consequently  increased  elim- 
ination, if  it  takes  place,  must  be 
through  the  kidneys;  great  interest, 
therefore,  attaches  to  the  influence  of  the 
remedy  upon  the  urinary  secretion.  In 
considering  this  the  effects  of  poisonous 
and  therapeutic  doses  must  not  be  con- 
founded, for  it  is  very  evident  that  an 
irritation  which  causes  suppression  of 
urine  may,  when  present  in  a  much 
milder  degree,  produce  an  increased  flow. 
When  the  drug  purges  freely  it  is  very 
probable  that  elimination  by  the  kid- 
neys is  lessened;  and  no  account  of  | 
this  is  taken  by  any  of  the  observers  I 
who  have  studied  its  effect  in  the  elim-  j 
ination  of  urea  and  uric  acid;  all  con- 
tent themselves  with  noting  the  propor- 
tion of  urea  and  uric  acid  in  the  urine, 
when  it  is  evident  that  the  mere  pro- 
portion, unchecked  by  the  absolute 
amount  of  urine  excreted  in  the  twenty-   ' 


four  hours,  is  no  criterion  as  to  the 
absolute  amount  eliminated.  H.  C. 
Wood  ("Therapeutics:  Its  Principles 
and  Practice,"  '94). 

By  some  observers  it  is  stated  that 
there  is  an  increased  elimination  both 
of  urea  and  uric  acid,  while  by  others 
it  is  denied.  It  is  possible  that  dif- 
ference in  dietary  of  the  patients  may 
account  for  this  discrepancy.  Murrell 
("Manual  of  Materia  Medica  and  Thera- 
peutics," '90). 

Full  medicinal  or  larger  doses  produce 
great  depression  of  the  circulation,  with 
a  small,  rapid,  and  thready  pulse.  The 
marked  cardiac  depression  and  collapse 
which  occur  when  poisonous  doses  have 
been  taken  are  more  the  result  of  the 
severe  gastroenteritis  than  of  any  direct 
action  upon  the  heart.  The  nervous 
system  is  unaflected  by  medicinal  doses; 
but  large  or  poisonous  doses  may  induce 
cerebral  excitement.  Large  doses  render 
the  respiratory  movements  slow  and 
shallow.  Personal  experiments  are  suf- 
ficient to  satisfy  the  author  that  the 
excretion  of  urea  and  uric  acid  by  the 
kidneys  is  considerably  heightened  un- 
der medicinal  doses.  Butler  ("Text-book 
of  Mat.  Med.,  Pharm.,  and  Ther.,"  '96). 
Colchicum  induces  fall  of  temperature 
during  the  period  of  emetocatharsia; 
when  injected  into  dogs  there  is  a 
marked  fall  in  blood-pressure.  The 
amount  of  urea  and  uric  acid  excreted 
in  the  urine  is  much  increased  by  the 
drug;  Lewins  found  the  urea  excreted 
to  be  almost  doubled  in  amount.  Biddle 
("Mat.  Med.  and  Ther.,"  '90). 

The  most  discordant  statements  have 
been  made  about  the  action  of  colchicum 
upon  the  renal  secretion,  but  it  has  not 
been    definitely    shown    that    either    the 
quantity  or  composition  is  altered.  After 
death  by  poisoning,  the  alkaloid  is  found 
in  the  blood  and  in  most  of  the  organs 
of  the  body.     Hale  White  ("Mat.  Med., 
Phar.,  and  Ther.,''  '90). 
Though   the   physiological   effects   of 
this  drug  are  very  similar  to  those  of 
veratrum,  yet  one  cannot  be  therapeutic- 
ally substituted  for  the  other.     It  pro- 
duces mucli  irritation  of  the  fauces,  with 
increase  of  saliva.     It  irritates  the  di- 


272 


COLCHICUM.    THERAPEUTICS. 


gestive  tract  and  produces  these  efEects 
whether  taken  into  the  stomach  or  in- 
jected into  the  veins.  In  large  doses  it 
considerably  increases  biliarj'  secretion, 
and  at  the  same  time  purges  powerfully. 
Colchicum,  it  is  well  known,  gives  re- 
lief from  the  pain,  inflammation,  and 
fever  of  gout.  But  how?  Does  it  cause 
the  elimination  of  uric  acid  through  the 
kidneys  and  so  remove  the  condition  on 
which  the  gout  immediately  depends? 
Since  Garrod  has  experimentally  shown 
that  colchicum  exerts  no  influence  on 
the  elimination  of  uric  acid  in  gouty 
people,  it  is  evident  that  the  drug  must 
control  gouty  inflammation  without,  in 
any  way,  afi"ecting  the  condition  on 
which  such  inflammation,  in  the  first  in- 
stance, depends.  Hence,  colchicum  should 
be  merely  palliative,  removing,  for  a 
time,  the  patient's  sufferings,  but  in  no 
way  protecting  him  from  their  recur- 
rence, ilany  who  suffer  from  gout  are 
of  opinion  that,  while  the  medicine  will 
remove  altogether  an  existing  attack,  it 
insures  the  speedy  return  of  another. 
Ringer  and  Sainsbury  ("Hand-book  of 
Ther.,"  '97). 

Colchicine  in  a  general  way  acts  like 
colchicum,  but  the  action  of  colchicein 
has  not  been  determined  with  any  degree 
of  definiteness. 

On  the  heart  and  circulation  colchicine 
produces  very  little  effect,  though  large 
doses  cause  a  fall  of  arterial  pressure 
and  slight  slowing  of  pulse,  due  to  de- 
pression of  the  heart. 

Colchicein,  in  poisonous  doses,  induces 
marked  weakness,  stupor,  and  lowering 
of  bodily  temperature;  decreases  reflex 
activity,  not  by  depressing  the  sensory 
nerves  as  does  colchicine,  but  by  acting 
on  the  motor  nerve-trunks.  Leon  (Univ. 
Med.  Mag.,  July,  Aug.,  '89). 

Two  or  three  hours  after  the  intrav- 
enous injection  of  colcliicine  the  symp- 
toms of  general  poisoning  appear.  The 
firBt  symptoms  are  nausea,  followed  by 
more  or  less  vomiting  and  diarrhoea; 
next,  alteration  in  the  motility,  taking 
on  the  form  of  ascending  central  paraly- 
sis. When  the  paralysis  reaches  the 
anterior  extremities,  disturbance  of  res-   ' 


piration  occurs:  the  respiratory  move- 
ments become  greatly  increased  in  power 
and  greatly  decreased  in  number,  until 
death  ensues,  owing  to  arrest  of  respira- 
tion. In  rare  cases,  immediately  before 
death,  convulsions  occur,  which  are  at- 
tributable to  asphyxia.  The  heart  re- 
mains beating  for  perhaps  twenty  min- 
utes after  breathing  has  been  arrested. 
Jacobi  (Schmidt's  Jahrbuch,  Sept.; 
Therap.  Gaz.,  Oct.,  '90). 

Severe  case  of  poisoning  by  two 
"Blair's  gout  pills,"  which,  as  is  well 
known,  contain  extract  of  colchicum. 
The  patient  had  a  typical  abdominal 
facies;  lips  and  nails,  bluish;  respira- 
tion, quick  and  shallow;  pulse,  small 
and  quick;  and  skin,  pale  and  clammy. 
He  vomited  a  large  amount  of  yellow 
fluid  and  nad  several  profuse  and 
bloody  passages  fi-om  the  bowels.  The 
temperature  was  96.5°  F.  Under  seda- 
tives and  carminatives  the  patient  re- 
covered. A  month  before  the  same  pa- 
tient had  taken  two  of  the  same  kind 
of  pills  with  similar,  but  much  less  in- 
tense, symptoms.  L.  G.  Davies  (Brit. 
Med.  Jour.,  Nov.  14,  1903). 

Colchicum  and  its  salts  are  contra- 
indicated  when  there  is  a  great  amount 
of  debility,  a  profuse  diarrhoea,  and  in 
asthenic  gout.  It  is  worthy  of  remark 
that  most  of  the  untoward  effects  chron- 
icled from  time  to  time  have  appeared  in 
conjunction  with  the  administration  of 
wine  of  colchicum-seed.  On  the  other 
hand,  much  of  tlie  corm,  or  "root,"  em- 
ployed by  manufacturers  is  worthless. 

Therapeutics.  —  Rheumatism  and 
Gout. — In  all  forms  of  sthenic  rheuma- 
tism and  gout  tlie  relief  that  colchicum 
gives  is  incomparably  greater  than  that 
afforded  by  any  other  single  remedy,  but 
the  mode  in  which  it  is  best  given,  tlie 
period  best  suited  for  its  administration, 
and  even  the  patients  for  which  it  is 
suited  are  points  whicli  demand  serious 
consideration.  It  is  by  no  means  an 
agent  to  be  prescribed  hap-Iiazard  and 
indiscriminately,  nor  one  which  will,  in 


C(JLC1IICUM.    THERAPEUTICS. 


273 


all  cases,  produce  equally  beneficial  re- 
sults. The  maxims  laid  down  by  Todd 
cannot  be  improved  upon,  viz.:  Never 
give  it  at  the  outset  of  a  paroxysm,  not 
until  the  bowels  have  been  acted  upon 
by  a  mild  purgative.  Let  the  first  doses, 
always,  be  small,  and  subsequently  grad- 
ually and  progressively  increased.  At 
first  administer  uncombined  with  any 
other  remedy  until  assurance  is  had 
that  it  is  not  likely  to  disagree  with  the 
patient;  and  do  not  push  to  a  degree 
that  will  excite  nausea,  vomiting,  or 
purging:  these  should  be  regarded  as  in- 
dicative of  unfavorable  operation.  It 
may  be  regarded  as  acting  favorably 
when,  under  its  use,  the  volume  of  urine 
is  increased;  when  an  abundant  supply 
of  bile  is  discharged;  when  the  feeees, 
though  solid,  are  surrounded  by  mucus; 
and  when  the  skin  secretes  freely.  Its 
effects  should  be  carefully  watched,  as 
it  is  likely  to  accumulate  in  the  system. 
It  is  inadmissible  where  the  patient  is 
advanced  in  years,  who  has  had  several 
attacks  and  in  whom  the  malady  seems 
too  deeply  rooted  to  be  influenced  by  the 
temporary  administration  of  the  remedy. 
It  is  necessary  to  continue  the  use  of 
colchicum  for  many  days  after  the  entire 
cessation  of  the  symptoms;  but  the  doses 
may  be  gradually  diminished,  and  at 
the  Bame  time  the  intervals  lengthened; 
also,  if  the  malady  does  not  give  way  by 
the  time  the  bowels  are  affected  by  the 
drug,  it  is  useless  to  push  it  further. 

Gout  is  the  one  disease  in  wliich  col- 
chicum is  almost  universally  recognized 
as  a  specific.  It  may  be  advantageou.sly 
employed  both  as  a  preventive  of  the 
paro.xysm  and  to  lessen  its  severity 
when  developed.  It  should  always  be 
borne  in  mind  that,  although  looseness 
of  the  bowels  may  be  useful,  yet  when 
colchicum  purges  the  gouty  patient 
actively  it  mostly  fails  in  achieving  the 
desired  therapeutic  result.  Its  action  is 
most    favorable    when    its    influence    is 

2—18 


felt  chiefly  upon  the  skin  and  kidneys; 
and  to  elTect  this  it  is  often  well  to 
restrain  the  tendency  of  the  drug  to  act 
upon  the  bowels  by  combining  it  with 
opium.  This  is  especially  the  case  in 
debilitated  subjects,  in  whom  anything 
like  overpurgation  must  be  avoided 
with  the  most  scrupulous  care.  By 
large  purgatives  doses  of  colchicum  the 
paroxysm  of  gout  may  often  be  sup- 
pressed, but  experience  has  shown  this 
use  of  the  drug  is  dangerous,  the  sup- 
pression being  sometimes  followed  by 
serious  internal  diseases,  apparently  due 
to  a  transfer  of  the  gouty  irritation. 
Between  the  paroxysms  colchicum  mar 
be  steadily  exhibited  to  the  gouty  sub- 
ject in  small  doses,  and  often  great  ad- 
vantage is  derived  from  its  combination 
with  potassium  iodide;  this  combina- 
tion is  especially  useful  in  irregular 
atonic  gout  such  as  is  frequently  seen  in 
women  of  feeble  nervous  organization 
who  have  inherited  the  diathesis,  but  is 
sometimes  present  in  robust  men.  H. 
C.  Wood  ("Therapeutics:  Its  Principles 
and  Practice,"  ninth  edition,  '94). 

While  efficacious  in  chronic  rheuma- 
tism and  occasionally  of  some  benefit  in 
rheumatoid  arthritis,  it  is  of  no  value  in 
acute  articular  rheumatism.  Its  value 
is  more  apparent  in  acute  than  in  chronic 
gout,  and  in  the  first  attacks  than  in 
succeeding  ones.  Chronic  gout,  as  well 
as  chronic  rheumatism,  yields  better  to 
a  combination  of  potassium  iodide  than 
to  colchicum  alone.  In  combination  with 
certain  other  agents  this  drug  serves  an 
excellent  purpose  as  a  cholagogue,  full 
doses  being  frequently  very  effective  in 
relieving  ascites  due  to  obstructive  dis- 
eases of  the  liver.  It  is  also  sometimes 
employed  as  a  drastic  purgative  in  cere- 
bral and  portal  congestion,  although 
when  given  in  doses  sufTicient  for  this 
purpose  it  occasions  considerable  nausea 
and  abdominal  distress.  It  has  also 
been  recommended  in  the  treatment  of 
gonorrhoea  and  chordee.  Hypochondria- 
sis resulting  from  renal  insufliciency  is 
frequently  benefited  by  this  remedy. 
Butler  ("Text-book  of  Mat.  Med..  Ther., 
and  Phar.,"  '96). 

Given  during  an  attack  of  gout  it  most 
markedly  relieves  pain;  in  smaller  doses, 


274 


COLCHICUM.    THERAPEUTICS. 


given  bet\Yeen  the  attacks,  it  diminishes 
their  severity.  It  is  often  very  useful 
for  dyspepsia,  eczema,  headaclie,  neu- 
ritis, conjuncti^'itis,  bronchitis,  and 
other  conditions  ^Yhich,  when  occurring 
in  those  suffering  from  gout,  are  prob- 
ably related  to  it.  Occasionally  it  is 
combined  with  other  eholagogues,  espe- 
cially if  it  is  desired  to  give  these  reme- 
dies to  a  person  who  is  the  subject  of 
gout.  Hale  White  ("Mat.  Med.  and 
Ther.,"  '96). 

Colchicum  is  a  remedy  of  undoubted 
value  in  gout  and  the  gouty  diathesis. 
The  larger  doses  of  the  drug  should  be 
reserved  exclusively  for  able-bodied  men 
of  the  brewer's-drayman  kind,  and  the 
effect  is  marvelous,  the  patient  usually 
being  able  to  resume  work  on  the  third 
day;  but  the  treatment  is  severe  and 
produces  persistent  purging  not  uncom- 
monly accompanied  by  vomiting.  In  less 
severe  eases  give  10  minims  of  colchicuni- 
wine  with  5  grains  of  potassium  iodide 
in  a  mixture  flavored  with  spirit  of 
chloroform  and  syrup  of  orange-flower, 
three  times  a  day;  this  often  acts  as  a 
laxative,  and  produces  a  peculiar  me- 
tallic taste  in  the  mouth;  many  patients 
take  this  mi.xture  at  intervals  all  the 
year  round.  Murrell  ("Manual  of  Mat. 
Med.  and  Ther.,"  '96). 

The  efl'ect  of  colchicum  on  gouty  in- 
flammation is  very  rapid;  a  large  dose 
will  often  relieve  the  most  severe  pain 
in  the  course  of  one  or  two  hours,  and 
soon  afterward  the  swelling  and  heat 
will  subside.  While  the  pain  is  thus 
quickly  subdued,  the  temperature  of  the 
body  falls  very  little  during  the  first  day, 
but  on  the  following  morning  there  is 
generally  a  considerable  decline,  and 
often  a  return  to  a  healthy  temperature; 
should  the  fall  be  postponed  a  longer 
time,  then  on  the  second  day  after  the 
use  of  the  colchicum  a  continuous  de- 
cline of  temperature  will  take  place,  and 
all  fever  gradually  disajipcar.  There  are 
two  methods  of  employing  the  drug: 
large  doses  which  extinguish  the  pain  at 
once,  and  small  doses  wliich  give  the 
same  result  only  after  some  days.  It  is 
BOmetimcH  used  in  chronic  rheumatism 
and  rheumatoid  arthritis,  b\it  without 
any  very  apparent  benefit.     Ringer  and 


Sainsbury   ("Hand-book  of  Ther.,"  thir- 
teenth edition,  '97). 

General  Maladies. — lu  dropsies — 
tlie  anasarca  of  the  aged,  hydrocephalus, 
hydrothorax,  anasarca  following  fevers, 
etc. — colchicum  is  often  very  efficacious, 
especially  in  combination  with  other 
diuretics  and  a  diuretic  alkali.  It  is  one 
of  the  most  satisfactory  remedies  in 
chronic  and  obstinate  constipation,  but 
the  dose  should  be  small,  as  the  object 
is  attained  rather  by  gradual  insinuation 
than  by  forcible  impression.  In  gonor- 
rhea and  other  inflammatory  discharges 
from  the  genito-urinary  organs,  in  both 
sexes,  in  strangury,  ardor  urinse,  and 
irritable  states  of  the  bladder,  it  has 
been  employed  with  great  success.  At 
one  time  it  was  held  to  be  the  most  effi- 
cient agent  known  to  therapeutics  in  re- 
moving tape-worm.  In  jaundice  and 
chronic  hepatitis  it  has  a  value,  but  re- 
quires to  be  combined  with  soap,  alkalies, 
or  mild  mercurials. 

Spasmodic  attempts  have  been  made 
toward  popularizing  the  alkaloid  col- 
chicine, but  with  little  success;  it  does 
not  sufficiently  represent  the  virtues  of 
colchicum.  It  has  found  its  best  applica- 
tion in  the  treatment  of  rheumatic  iritis, 
and  its  value  here  is  greatly  enhanced  by 
combining  with  methyl-salicylate.  It  has 
also  been  employed  subcutaneously  in 
chronic  rheumatism  and  neuralgic  joint- 
affections. 

A  valuable  remedy,  and  in  conjunction 
with  small  doses  of  calomel  may  be  pre- 
scribed with  advantage  for  gouty  people 
who  have  had  no  acute  manifestation  of 
the  disease,  but  who  sudor  more  or  less 
continuously  from  joint-pain.  A  pill 
may  be  taken  at  bed-time,  or  three  times 
a  day  after  meals,  composed  of:  Vm 
Krain  of  colchicine,  Vs  grain  of  calomel, 
and  1  grain  of  solid  extract  of  henbane. 
In  gouty  neuritis  a  pill  three  times 
daily^of  colchicine,  '/«»  quinine  and 
extract  of  colocynth,  of  each,  1  grain — 


COLOCYNXH.    PREPAKATIONS  AND  DOSES. 


275 


ia  recommended.     Murrell    ("Manual   of 
Mat.  Med.  and  Ther.,"  '9U). 

For  hypodermic  use  the  alkaloid  may 
be  dissolved  in  distilled  water  in  the  pro- 
portion of  1  to  5G0  minims,  the  dose 
being  15  minims;  but  the  injection 
causes  sharp  burning  pain.  Wlien  deep, 
intramuscular  injections  have  been  tried 
in  sciatica,  the  results  have  been  un- 
fortunate and  unprofitable. 

G.  Abciiie  Stockwell, 

New  York. 

COLD  ABSCESS.     See  Abscess. 

COLITIS.     See  Intestines. 

COLOBOMA.    See  This  and  Lens. 

COLO  CYNTH.— This  is  the  dried,  de- 
corticated fruit,  freed  from  seeds,  of  Ci- 
trullus  colocynth,  a  perennial  plant  re- 
sembling the  watermelon;  it  is  also 
known  as  "bitter  apple"  and  "hitter  cu- 
cumber." Though  grown  in  gardens  in 
England  since  1551,  the  plant  is  a  native 
■of  the  deserts  and  places  of  southern  and 
western  Asia,  and  of  Africa;  it  is  like- 
wise cultivated,  medicinally,  in  Greece, 
Spain,  Italy,  and  Japan.  Two  varieties 
of  fruit  are  recognized  pharmacologic- 
ally: one  termed  "peeled  Turkey"  colo- 
cynth, imported  chiefly  from  Smyrna, 
Trieste,  and  Spain,  and  "unpeeled  moga- 
<lor,"  from  different  parts  of  India, 
Africa,  and,  to  some  extent,  from  the 
Persian  Gulf  and  the  Levant. 

The  fruit  is  globular,  about  the  size  of 
&  small  orange,  yellow  and  smooth  when 
ripe,  and  usually  gathered  just  as  the 
latter  process  is  beginning,  when  it  is 
peeled  and  dried  quickly,  either  in  the 
•eun  or  by  artificial  heat.  As  found  in 
the  shops,  it  is  in  white  balls  that  are 
very  light  and  spongy;  about  three- 
fourths  of  its  weight  is  claimed  by  the 
seeds,  which  are  not  employed  medici- 
nally, though  sometimes  used  in  small 
proportions  for  purposes  of  adulteration. 
The  British  Pharmacopoeia  demands  a 


test  that  shall  prove  the  colocynth  to  be 
wholly  oil-free  as  evidence  that  such 
adulteration  has  not  taken  place,  since 
such  is  a  seed-product  solely.  Colocynth 
is  inodorous,  nauseatingly  bitter,  and 
yields  a  glucoside  termed  "colocynthi- 
din"  and  a  resin  known  as  "citruUin,"  or 
"colocynthitin,"  the  latter  not  being 
identical,  however,  with  the  colocynthitis 
of  Walz. 

Preparations  and  Doses. — Colocynth 
pulp,  powdered,  2  to  10  grains. 

Colocynth  extract,  compound  (colo- 
cynth, 16;  aloes,  50;  cardamom,  6;  scam- 
mony  resin,  14;  soap,  14;  and  alcohol, 
10  parts),  5  to  20  grains. 

Colocynth  extract,  fluid,  2  to  5  minims. 

Colocynth  extract,  solid,  1  to  3  grains. 

Colocynth  pills,  compound  (compound 
cathartic  pills),  1  to  3  pills. 

Colocynth  pills,  compound,  with  hen- 
bane, 1  to  5  pills. 

Colocynth  tincture  (10  per  cent.),  30 
to  GO  minims. 

Colocynthidin,  Vj  to  "/a  grain. 

Colocynthin  resinoid  (concentration), 
V^o  to  V,o  grain. 

Coloc}'nthitin  (citrullin),  Ve  to  Vi 
grain. 

Powdered  colocynth  is  now  but  spar- 
ingly used,  the  extract  serving  a  much 
better  purpose. 

Compound  colocynth,  or  cathartic, 
pills,  are  made  in  two  ways.  First  by 
making  a  mass  of  compound  extract  of 
colocynth,  130;  powdered  extract  of 
jalap,  100;  calomel,  100;  and  gamboge, 
25;  to  make  100  pills.  Second,  by  beat- 
ing together  colocynth-pulp,  4;  Barba- 
does  aloes,  S;  scammony  resin,  8  parts; 
and  potassium  sulphate  and  oil  of  clove, 
of  each,  1  part.  It  is  often  used  in  form 
of  powder  in  doses  of  from  5  to  10  grains, 
and  is  easily  identified  by  the  odor  of 
cloves.  The  so-called  "vegetable"  com- 
pound cathartic  pill  drops  the  calomel 


276     COLOCYXTH.    PHYSIOLOGICAL  ACTION.    POISONING.    THERAPEUTICS. 


and  gamboge,  and  substitutes  leptandrin, 
resin  of  podophyllin,  henbane,  and  oil  of 
peppermint. 

Colocynth  pill  with  hyoscyamus  is 
made  by  mixing  2  parts  of  the  compound 
colocynth  pill  (second  formula  just 
given),  with  1  part  of  solid  extract  of 
henbane.  It  is  not  so  liable  to  gripe  as 
is  the  pill  colocynth  compound,  and  the 
dose  is  the  same  as  the  latter:  5  to  10 
grains. 

The  glucoside  colocynthidin,  which  is 
identical  with  the  colocyntMn  of  Merck, 
appears  as  a  yellow  powder  soluble  in 
water  and  alcohol,  and  is  frequently  used 
in  enema  by  mixing  from  4  to  16  minims 
of  a  4-per-cent.  solution  in  glycerin  and 
ale. 

The  concentration  colocjTithin  is  ob- 
tained by  evaporation  from  an  alcoholic 
tincture  as  a  chocolate-colored  powder 
soluble  in  alcohol  only. 

"Walz's  colocynthitin  is  a  tasteless  crys- 
tal powder;  but  citrullin,  which  often 
obtains  this  title,  is  a  yellowish,  amor- 
phous powder,  soluble  in  alcohol,  glyc- 
erin, and  ether,  and  finds  more  use  in 
veterinary  practice  than  elsewhere, 
though  it  is  sometimes  employed  for  its 
cathartic  effect,  preferably  by  supposi- 
tory or  in  enema,  in  general  medicine. 

Physiological  Action.  —  Colocynth 
preparations  and  derivatives  stimulate 
the  secretions  throughout  the  prima  vice, 
and  in  full  doses  are  apt  to  produce  con- 
siderable irritation  of  the  large  intestine, 
causing  profuse  watery  evacuations.  If 
given  in  excessive  doses,  fatality  may 
be  induced  by  provoking  inflammation, 
leading,  perhaps,  to  ulceration.  The 
drastic  effects  of  the  drug  and  its  tend- 
ency to  cause  griping  are  readily  over- 
come by  prescribing  partly  with  other 
purgatives  and  partly  with  carminatives, 
more  particularly  extracts  of  henbane  or 
belladonna  or  monobromated  camphor. 


The  drug  is  likewise  actively  cholagogic, 
and  to  some  degree  diuretic. 

Colocynth  Poisoning. — This  is,  fortu- 
nately, very  rare,  less  than  a  score  of  cases 
appearing  in  literature.  Christison  de- 
scribes a  case  in  which  a  teaspoonful  and 
a  half  of  the  powder  killed  a  man,  and 
Huseman  mentions  an  instance  where 
40  grains  proved  fatal,  though  another 
case  of  his  recovered  after  3  drachms  had 
been  ingested.  The  toxic  sj'mptoms  are 
hypercatharsis,  and  evidences  of  power- 
ful gastro-intestinal  irritation.  The 
treatment  consists  of  administering  evac- 
uants,  demulcents,  opiates,  and  stimu- 
lants. 

Therapeutics. — This  drug  is  chiefly 
employed  for  its  stimulating  effect  upon 
the  liver  and  the  intestines,  or  when  a 
rapid,  efficient,  drastic  purgative  action 
is  desired.  It  renders  the  bile  more  fluid 
and  watery,  at  the  same  time  increasing 
the  secretion  of  biliary  matter. 

Gasteo-Intestinal,  Dropsical,  and 
Gouty  Disohders.  —  Colocynth  is  a 
favorite  remedy  in  habitual  constipation 
and  various  dyspeptic  conditions;  but  it 
is  contra-indicated,  except  in  minute 
doses,  in  inflammatory  conditions  of  the 
intestinal  canal.  In  dropsical  affections, 
too,  particularly  when  connected  with 
disease  of  the  liver,  it  is  often  effective,^ 
particularly  if  a  hydragogue  action  is  se- 
cured by  combining  with  a  little  ela- 
terium.  In  fact,  in  most  conditions  ac- 
companied by  constipation  or  visceral 
obstruction  the  drug  is  eligible. 

Colocynth  i8  one  of  the  most  prompt 
and  powerful  lemedies  for  the  relief  of 
enteric  colic.  It  nmkes  some  very  eatis- 
factovy  curea  in  eliolera  infantum  and 
dysentery,  being  especially  indicated 
when  the  disease  is  attended  by  intense 
pain — when  pain  is  a  prominent  fcalvire 
of  the  complaint.  And  though  the  drug 
seems  to  influence  the  circulation  of  the 
lower  bowel  to  a  marlced  extent,  it  is 
more  a  remedy  for  neuralgic  than  for 


COLOCYNTH. 


CONJUNCTIVA. 


277 


circulatory  disturbances,  and  relieves 
neuralgic  colic  magically  in  many  in- 
stances; however,  it  is  adapted  to  pain 
in  any  portion  of  the  alimentary  canal 
below  the  esophagus,  and  will  prove 
useful  in  many  a  case  of  gastralgia  of 
neuralgic  character.  In  minute  doses  it 
is  serviceable  in  the  treatment  of  con- 
stipation in  children  and  delicate  females 
when  other  remedies  would  be  objection- 
able.    Webster  ("Dynam.  Therap.,"  '93). 

Is  a  favorite  remedy  in  dropsical  con- 
ditions to  produce  watery  stools,  in  cases 
in  which  other  resorbents  are  contra-in- 
dicated.   Roth  ("Mod.  Mat.  Med.,"  '95). 

Is  a  good  remedy  in  passive  dropsy 
from  visceral  obstruction,  provided  the 
patient  is  not  debilitated;  also  in  dys- 
pepsia when  there  is  a  bitter  taste  in  the 
mouth,  bloating  of  the  stomach  after  eat- 
ing, and  colicky  or  sharp,  cutting  pains 
in  the  region  of  the  umbilicus.  For  bil- 
ious or  worm  colic  it  is  a  very  important 
remedy;  likewise  in  many  diseases  of 
the  liver.  It  does  good  service  in  chronic 
diarrhoea  when  the  stools  are  slimy  and 
attended  with  sharp  cutting  pain  and 
distension  of  the  abdomen.  It  is  serv- 
iceable in  some  cases  of  dysentery  and 
again  in  neiiralgias  of  the  fifth  nerve. 
Locke  ("Jfat.  Med.  and  Therap.,"  '95). 

In  small  doses  the  drug  acts  as  a 
stomachic,  improving  the  appetite  and 
augmenting  the  secretion  of  the  whole 
gastro-intestinal  tract;  it  is  also  a  de- 
cided hepatic  stimulant  and  eholagogue, 
and  useful  to  produce  abundant  watery 
evacuations,  as  is  necessary  sometimes  in 
the  treatment  of  hepatic  and  renal  dis- 
eases where  there  is  constipation  and 
ascites.  Gastro-intestinal  inflammation, 
pregnancy,  etc.,  contva-indicatc  its  use. 
Butler  ("Text-book  of  Mat.  Med., 
Therap.,  and  Pharm.,"  '90). 

The  drug  has  been  used  to  cause  the 
disappearance  of  long-continued  dropsies 
and  fluid  effusions,  but  this  employment 
is  not  to  be  recommended.  Griffin  (Fos- 
ter's "Prac.  Therap.,"  vol.  i,  '9G). 

Apoplexy,  Mania,  and  Cerebral 
Affections. — Here  the  drug  is  often 
particularly  useful  as  a  powerful  ca- 
thartic and  derivative,  hut  requires  to 
be  exhibited  in  full  doses  and  repeated 


until  it  operates  freely.     Croton-oil  is 
generally  preferred,  however. 

Hypodermic  Administration. — The 
claim  has  been  repeatedly  advanced  that 
the  glucoside,  given  subcutaneously,  is 
actively  purgative.  Some  experiments, 
lasting  several  months,  undertaken  for 
definitely  proving  or  disproving  this, 
were  undertaken  by  responsible  persons, 
in  the  laboratory  of  a  large  firm  of  manu- 
facturing pharmacists  and  chemists,  and 
the  evidence  was  wholly  negative. 

COLON,  DILATATION  OF.  See  In- 
testines. 

COLPITIS.    See  Vagina,  Vaginitis. 

COLPOPTOSIS.     See  Vagina. 

COMPOUND  FEACTUHES.  See 
Fractures. 

COMPRESSION  OF  BRAIN.     See 

Head,  Injuries  of. 

CONCUSSION   OF  BRAIN.     See 

Head,  In.iuries  of. 

CONDYLOMA.     See  Syphilis. 

CONGESTION  OF  LUNGS.     See 

Pulmonary  Circulation. 

CONJUNCTIVA,  DISEASES  OF  THE. 

— The  conjunctiva  is  more  frequently  in- 
flamed than  any  other  ocular  tissue;   it 
is  not  only  exposed  to  invasion  by  hosts 
of  bacteria,  but  it  offers  a  favorable  nidus 
for  their  development.    The  pathogenic 
micro-organisms  may  be  carried  into  it8 
folds  in  many  diHerent  ways:    through 
the  medium  of  the  hands,  towels,  hand- 
kerchiefs, etc.,  through  the  lacrymal  pas- 
sages, and  from  the  nasal  mucous  mem- 
brane by  direct  continuity  of  structure. 
Tears  have  the  power  of  diminishing 
the  number  of  the   staphylococcus  py- 
ogenes aureus  and  the  bacillus  subtilis. 
Their  virulence,  however,  is  not  afTected. 
The   gonococcus    and    micrococcus    pro- 


278 


CONJUNCTIVA.     HYPER.EMIA.    INFLAMMATION. 


digiosus    were     unchanged.      Bernheim 
(Corres.  f.  schweizer  Aerzte,  Aug.  I,  '93). 
Investigations  of  one  hundred  healthy 
eyes.     The   normal   conjunctiva   always 
contains     bacteria,     among    which    the 
staphylococcus  epidermis  albus  is  found 
with   such   frequency   that   it   must  be 
regarded  as  a  regular  inhabitant  of  the 
conjunctival    cul-de-sac.      This    coccus, 
though    but    slightly    pathogenic    ordi- 
narily, may,  under  certain  conditions,  be- 
come harmful.     Neither  irrigation  with 
distilled  water  nor  instillation  of  a  1  to 
5000   solution   produces   sterility   of  the 
conjunctiva.      R.    Randolph    (Arch,    of 
Ophth.,  July,  '07). 
Hypersemia  of  the  Conjunctiva. — Con- 
junctival  hypertemia  may  either  be  pas- 
eive  or  active.    Passive  hyperffimia  exists 
after  paralysis   of  the   cervical  sympa- 
thetic, or  as  a  result  of  some  interference 
with  the  proper  circulation  of  blood  in 
the  membrane,  or  it  may  be  associated 
with  disorders  of  the  general  systemic 
condition,  especially  gout. 

Active  hyperemia  is  a  prelude  to  all 
Inflammatory  conditions  of  the  conjunc- 
tiva, but  may  be  occasioned  by  the  pres- 
ence of  a  foreign  body  or  a  misplaced 
cilia,  or  by  the  irritative  action  of  dust 
and  smoke.  It  is  a  frequent  exponent 
of  some  error  of  refraction  or  of  muscular 
insufficiency,  and  is  often  associated  with 
a  catarrhal  condition  of  the  nose  and 
throat  and  with  disease  of  the  lacrymal 


The  conjunctival  congestions  described 
by  Jonathan  Hutchinson  as  characteris- 
tic of  masked  gout  are  usually  confined 
to  one  eye.  The  conjunctiva  becomes 
red,  and  the  eyeball  feels  hot  and  pricks 
as  if  it  contained  sand.  The  attack  may 
come  on  within  half  an  hour  of  the  meal 
which  has  disagreed,  and  it  may  last  for 
a  few  liours  or  a  day  or  two.  The  fuga- 
cious periodical  episcleritis  of  Fuchs  is 
the  same  disorder.  In  this  the  conges- 
tions come  on  rather  suddenly  and  pre- 
sent themselves  in  the  form  of  patches 
of  hyperemia  of  the  sclera  and  over- 
lying  conjunctiva.     They   may   have   a 


violet  hue,  and  are  associated  with  burn 
ing  and  itching.  These  symptoms  are 
personally  thought  to  be  the  indication 
of  vascular  changes  deep  in  the  ocular 
coats,  which  in  their  turn  are  significant 
of  wide-spread  arterial  changes  through- 
out the  body.  G.  E.  de  Schweinitz 
(Maryland  Med.  Jour.,  June,  1900). 

Symptoms. — There  is  a  smarting, 
burning,  and  itching  sensation  in  the 
eyes,  the  lids  feel  heavy,  and  there  is  a 
disinclination  to  prolonged  near  and  fine 
work.  On  eversion  of  the  eyelids  the 
mucous  membrane  is  found  to  be  abnor- 
mally red  and  perhaps  a  little  swelled, 
while  the  Meibomian  glands,  imbedded 
in  the  tarsus,  are  rendered  indistinct  by 
dilated  meshes  of  blood-vessels.  The  in- 
jection of  the  vascular  supply  may  be 
limited  to  the  conjunctiva  of  the  lids  or 
involve  that  of  the  globe  also.  There 
may  be  a  slight  increase. in  the  flow  of 
tears,  but  there  is  never  any  discharge. 

Treatment.— Treatment  of  hypercemia 
of  the  conjunctiva  resolves  itself  into  the 
removal  of  the  cause.  If  of  paasiye 
origin,  the  removal  of  the  obstruction  to 
the  circulation  will  be  followed  by  the 
rapid  subsidence  in  the  undue  vascu- 
larity. If  of  active,  the  correction  of 
any  existing  anomaly  of  refraction  or  of 
muscle-balance,  or  the  removal  of  any 
foreign  body,  will  accomplish  the  same 
result.  Dark  glasses  should  be  given  to 
protect  the  eyes  from  irritating  rays  of 
light,  and  from  dust  and  smoke,  and  a 
boric  wash  or  some  other  mild  antiseptic 
or  astringent  lotion  will,  with  cold  com- 
presses, be  sulTicient  to  reduce  the  ves- 
sels to  their  normal  size. 

Inflammation  of  the  Conjunctiva.— 
When  an  increased  and  perverted  secre- 
tion is  added  to  the  symptoms  of  hyper- 
(cmia,  the  conjunctiva  may  l)c  said  to  be 
inflamed. 

All  varieties  of  conjunctivitis  are  con- 
tagious, and,  while  they  occasion  certain 


CONJUNCTIVA.     CATARRHAL  CONJUNCTIVITIS.     SYMPTOMS. 


279 


fixed  changes  in  the  tissues,  which  per- 
mit of  their  being  grouped  into  certain 
types,  they  have  this  peculiarity,  that  the 
secretion  from  one  type  when  inoculated 
into  a  healthy  eye  may  set  up  quite  a 
different  variety  of  conjunctival  inflam- 
mation from  that  of  the  eye  from  which 
it  was  obtained;  this,  therefore,  shows 
that  the  secretion  of  the  different  forms 
cannot  be  regarded  as  being  specific, 
but  that  the  type  of  inflammation  set 
up  by  it  depends  upon  other  causes  as 
well. 

Corneal  involvement  is  a  common 
complication  of  all  forms  of  conjuncti- 
vitis and  must  always  be  regarded  in  the 
prognosis,  as  its  occurrence  usually  indi- 
cates that  there  will  be  a  permanent  dis- 
turbance in  vision  after  the  subsidence 
of  the  inflammation. 

According  to  the  nature  of  the  secre- 
tion and  the  character  of  the  patholog- 
ical changes  observed  in  the  tissues  of 
the  conjunctiva,  inflammations  of  that 
membrane  have  been  divided  into  the 
catarrhal,  diphtheritic,  purulent,  granu- 
lar, and  phlyctenular  varieties. 

Catarrhal  Conjunctivitis. 

Symptoms. — In  the  simple  form  the 
conjunctiva  is  red,  vascular,  and  swelled, 
the  vessels  usually  forming  a  large,  coarse 
net-work.  At  first  these  changes  are  lim- 
ited to  the  palpebral  conjunctiva;  but 
they  soon  extend  to  the  retrotarsal  fold, 
the  caruncle,  and  semilunar  folds,  and 
finally  to  the  bulbar  conjunctiva.  The 
surface  of  the  membrane  is  smooth,  serv- 
ing to  differentiate  it  from  other  forms 
of  conjunctival  inflammation.  The  eye- 
lids are  slightly  swelled,  and  their  edges 
reddened  and  covered  with  3'ellowish 
crusts,  and  bathed  with  an  abundant  se- 
cretion. 

Severe  cases  arc  characterized  by  the 
involvement  of  the  bulbar  conjunctiva, 


and  by  an  increase  in  the  redness  and 
swelling  of  the  palpebral  portion  of  the 
membrane  and  of  the  retrotarsal  folds. 
The  net-like  formation  of  blood-vessels 
can  no  longer  be  differentiated;  small 
hemorrhages  appear,  scattered  through 
the  membrane,  and  there  is  a  serous  in- 
filtration from  both  the  superficial  and 
deep  vessels.  This  fluid  collects  in  the 
submucous  tissue  and  occasions  chemosis. 

The  lymph-follicles  may  develop,  and 
the  papilla3  of  the  conjunctiva  become 
swelled  and  turgid  and  give  to  the  mem- 
brane a  rough  and  granular  appearance. 

In  chronic  forms  the  objective  symp- 
toms are  not  prominent.  There  is  mod- 
erate swelling  and  congestion  of  the  con- 
junctiva and  but  slight  secretion,  the 
symptoms  being  those  of  hyperemia. 

There  is  a  constant  sense  of  heaviness 
and  a  sensation  of  sand  in  the  eyes;  there 
is  burning  and  watering,  and  vision  is 
momentarily  blurred  by  some  of  the  se- 
cretion covering  the  pupillary  area  of  the 
cornea. 

Complications. — Secondary  corneal  in- 
volvement occurs  in  the  aged,  especially 
when  the  catarrh  has  persisted  for  years. 
The  ulcers  are  usually  at  the  limbus,  and 
their  formation  is  attended  with  pain 
and  photophobia.  They  appear  as  small, 
round,  gray  points,  which  may  become 
confluent  and  form  a  crescentic  ulcer. 
These  usually  heal,  leaving  small,  bow- 
shaped  nebulce.  Iritis  may  also  present 
itself,  and  is  usually  the  result  of  kera- 
titis; but  it  may  also  be  seen  in  severe 
cases  of  conjunctivitis  without  involve- 
ment of  the  cornea. 

In  gouty  persons  there  is  a  form  of 
conjunctivitis  to  which  the  name  of 
"catarrho-rheumatic  ophthalmia"  has 
been  given,  which  is  attended  with  great 
pain  in  the  eyes  and  temples  and  great 
photophobia.  There  is  usually  marked 
lacr3Tnation,  but  no  discharge. 


280 


CONJUNCTIVA.     CATARRHAL  CONJUNCTIVITIS.     ETIOLOGY. 


Singular  and  rare  conjunctival  affec- 
tjon  occurring  in  arthritic  persons,  and 
in   those   affected   with   arteriosclerosis, 
consisting  of  the  onset  of  an  active  hy- 
perjemia  of  the  conjunctiva  coming  on 
suddenly,  without  appreciable  cause,  and 
disappearing  spontaneously,  the  attacks 
almost    always    coming    on    during   the 
night,  lasting  three  or  four  hours,  and 
recurring  regularly  two   or  three  times 
at  intervals  of  twenty-four  hours.     M. 
Trousseau  (Eecueil  d'Ophtal.,  No.  G,  "90). 
Case  of  conjunctivitis  after  rheuma- 
tism  in   which    there    was    a   catarrhal 
conjunctivitis  and  a  peripheral  keratitis 
after   a    severe    attack    of   rheumatism. 
The  cornea  was  infiltrated  at  its  mar- 
gin, the  opacity  extending  inward   for 
some    distance,   but   merging   gradually 
into  the  normal  transparent  center  of 
the    cornea.     This    secondary    purulent 
keratitis  may  be  found  as  the  result  of 
a  number  of  infectious  diseases,  but  in 
this     instance    it    was    the    result     of 
rheumatism.     The     keratitis     improved 
as  the  condition  of  the  joints  got  bet- 
ter.    Ortali     (Gaz.     degli    Osped.     delle 
Clin.,  Sept.  20,  1903). 
Etiology. — Catarrh  of  the  conjunctiva 
may  be  originated  by  any  of  the  causes 
of  hyperemia  of  the  conjunctiva.    It  may 
be  the  product  of  foul  air  or  of  poorly- 
ventilated  rooms,  especially  when  large 
numbers  of  people  are  crowded  together, 
as  in  tenements,  etc.;  professions  which 
expose  the  eyes  to  overuse  or  the  pro- 
longed   action    of   irritative   gases   and 
vapor,  dispose  to  it,  or  it  may  be  set 
up  by  contact  with  a  leucorrhoeal  dis- 
charge.    It  is   common   in   warm   and 
changeable  weather,  when  it  may  assume 
an  epidemic  form.     Staphylococci  and 
streptococci  are  almost  always  present, 
and   the  diphtheritic  bacillus  likewise. 
Weeks  has  found  small  bacteria  in  "pink- 
eye," which,  when  inoculated  upon  the 
conjunctiva  of  the  rabbit,  has  produced 
this  form  of  catarrhal  conjunctivitis. 

In  Hubacute  catarrhal  conjunctivitis 
the  germ  commonly  found  is  a  diplobacil- 
luB,  Vi  niillimetre  in  length  by  '/t  milli- 


metre in  breadth.  With  pure  cultures 
Morax  was  able  to  reproduce  the  disease 
in  man.  The  diplobacillus  personally  ob- 
served in  diverse  conditions  of  the  con- 
junctiva. It  grows  readily  upon  pig- 
serum  and  serum-agar,  the  serum  being 
liquefied  all  along  the  line  of  growth, 
which  broadens  if  the  tube  is  kept  in  the 
oven,  until  in  some  cases  the  whole  sur- 
face of  the  slant  is  broken  down. 

In  the  secretion  the  germ,  while  show- 
ing some  individual  variation  in  size,  is, 
on  the  whole,  quite  uniform.  The  large, 
thick,  double  rod  is  the  almost  invariable 
form,  each  member  of  the  pair  frequently 
showing  an  indistinct  subdivision  at  its 
middle.  In  culture  there  is  more  variety 
in  the  forms  to  be  seen.  The  germ  stains 
very  readily,  dilute  carbol-fuehsin  giving 
the  best  pictures.  It  is  decolorized  by 
Gram's  method. 

It  is  evident  that  the  appearance  of  the 
eyes  infected  with  this  germ  is  anything 
but  uniform,  but  in  the  great  majority 
of  cases  the  symptoms  are  subacute  or 
chronic  in  character.  They  yield  quickly 
to  a  Vo-per-cent.  solution  of  zinc  chloride 
dropped  into  the  eyes.  H.  Gifl'ord  (An- 
nals of  Oph.,  vol.  vii.  No.  2,  '98). 

From  epidemic  occurring  in  Vittoria 
in  1899  the  following  conclusions  drawn: 
1.  Pneumococcic  catarrhal  conjunctivitis 
is  a  contagious  allcction,  which  occurs 
endemically  or  in  epidemics,  attacks  in- 
dividuals at  all  ages,  and  usually  runs 
an  acute  course  of  about  ten  days'  dura- 
tion, but  may  become  chronic.  It  is  of 
a  rather  benign  nature,  and  rarely  af- 
fects the  eye  itself.  It  is  produced  by 
Fraenkel's  pneumococcus.  2.  The  eases 
personally  observed  during  the  aforesaid 
epidemic  were  essentially  cases  of  the 
pneumococcic  variety  of  conjunctivitis. 
G.  Gonsalvo  (Gaz.  degli  Osped.  e  delle 
Clin.,  Sept.  30,  1900). 

The  Koch-Weeks  bacillus  of  conjunc- 
tivitis may  present  itself  in  a  partic- 
ularly severe  form,  and  be  complicated 
by  phlyctenules  and  even  by  corneal 
ulceration.  Such  eases  are  especially 
contagious,  and  extra  precautions  should 
bo  taken  to  prevent  their  spreading,  par- 
ticularly among  the  school-children.  As 
a  rule,  they  are  controlled  by  the  use  of 
milil  astringent  lotions,  and  applications 


CONJUNCTIVA.    CATARRHAL  CONJUNCTIVITIS.    TREATMENT. 


281 


of  2-per-eent.  solutions  of  nitrate  of 
silver.  E.  A.  Sliumway  (Pbila.  Med. 
Jour.,  April  20,  1902). 
The  course  of  this  variety  of  conjunc- 
tivitis is  usually  favorable,  uncomplicated 
cases  recovering  in  from  one  to  two 
weeks.  In  adults,  however,  especially  if 
there  be  a  history  of  alcoholism,  albu- 
minuria, or  diabetes,  the  disease  may  as- 
sume a  chronic  form.  Both  eyes  are 
usually  affected,  either  at  the  same  time 
or  the  second  eye  a  few  days  later.  The 
disease  may  begin  as  an  hyperemia  and 
slowly  go  over  into  catarrh,  or  the  onset 
may  be  more  abrupt.  In  institutions 
where  there  are  poor  hygienic  conditions, 
the  disease  usually  becomes  chronic  and 
epidemic. 

Treatment.  — •  Attention  should  be 
given  to  the  general  health.  Any  exist- 
ing systemic  disease,  such  as  rheuma- 
tism, diabetes,  or  albuminuria,  should  be 
combated,  shorter  working-hours  should 
be  prescribed  for  professional  men  and 
more  exercise  recommended;  the  eyes 
must  be  properly  protected  from  the 
light,  air,  and  dust  with  smoked  glasses, 
and  they  should  be  kept  clean  from 
discharge  by  frequent  washings  with 
boric-acid  lotion;  great  relief  may 
also  be  obtained  from  the  applica- 
tion of  ice-compresses.  These  are  best 
applied  as  follows:  1.  Several  pads 
of  gauze  of  three  or  four  thicknesses, 
about  the  size  of  a  silver  dollar,  are  laid 
on  a  block  of  ice.  The  ice  should  be  sus- 
pended in  a  receptacle  with  perforations 
in  its  bottom  which  will  permit  the  water 
and  any  secretion  from  the  compress  to 
drain  off  into  a  jar  beneath  it.  An  or- 
dinary kitchen-collander  and  wash-basin 
will  answer  very  well  for  this  apparatus. 
One  of  the  pads  is  taken  from  tlie  ice  as 
soon  as  it  has  been  saturated  and  is  ap- 
plied to  the  closed  lids,  removed  in  a  few 
moments,'and  a  fresh  one  substituted  foi 
it.     2.  Compresses  of  absorbent  cotton 


which  have  been  soaked  in  ice-water  may 
also  be  employed.  They  should  be 
squeezed  out  sufficiently  to  prevent  any 
of  the  water  trickling  over  the  patient's 
face  and  neck.  3.  Cold  may  also  be  ap- 
plied by  means  of  the  ordinary  douche 
or  by  holding  a  small  cake  of  ice  directly 
to  the  eye;  but  these  should  be  dis- 
carded for  the  compress,  as  they  can  only 
be  used  intermittently. 

To  avoid  repetition  it  seems  well  at 
this  place  to  give  the  indications  which 
call  for  the  emplojnnent  of  hot  and  cold 
compresses,  not  only  in  the  treatment  of 
catarrhal  conjunctivitis,  but  also  of  the 
other  forms  of  conjunctivitis  as  well. 

In  hypera?mia  of  the  conjunctiva,  in- 
duced by  ametropia  or  the  presence  of  a 
foreign  body,  we  have,  in  cold,  a  simple, 
but  effective,  means  of  restoring  the 
membrane  to  its  healthy  condition.  In 
these  cases  the  douche  or  the  compress 
may  be  applied  over  the  closed  lids,  with 
the  greatest  advantage,  for  fifteen  min- 
utes at  a  time.  The  water  employed 
should  not  be  too  cold,  or  excessive  reac- 
tion may  follow  its  use. 

In  the  treatment  of  the  milder  form 
of  conjunctivitis  the  membrane  may  be 
sprayed  with  a  solution  of  boric  acid  and 
salt,  the  good  efTects  of  this  plan  being 
probably  due  to  the  fact  that  the  liquid 
thus  applied  penetrates  the  deeper  tis- 
sues and  correspondingly  increases  the 
extent  of  the  contact  and  prolongs  the 
action  of  the  drug.  De  Schweinitz 
(Amer.  Jour,  of  Ophth.,  St.  Louis,  Jan., 
'94). 

A  2-pcrcent.  solution  of  extract  of 
suprarenal  capsule  will  cause  a  certain 
amount  of  contraction  of  the  blood-ves- 
sels in  an  eye  not  inflamed,  while  a 
3-,  4-,  or  5-per-cent.  solution  will  produce 
a  decided  blanching  of  the  ocular  and 
palpebral  conjunctiva  within  n  couple  of 
minutes  after  the  application  is  made, 
even  though  the  engorgement  of  the  ves- 
sels be  considerable.  The  contraction  of 
the  blood-vessels  does  not  last  long,  how- 
ever, and  as  they  begin  to  dilate  they  re- 


282 


COXJUXCTIVA.    FOLLICULAR  COXJUXCTIVITIS. 


turn  gradually  to  the  condition  existing 
before  the  application  was  made.  Bates 
(X.  Y.  Med.  Jour.,  May  IC,  '96). 

Aqueous  extract  of  suprarenal  capsule 
produces  great  bleaching  of  the  conjunc- 
tiva, but  after  the  astringent  action  has 
passed  away  the  inflammation  returns 
In  greater  force  than  before.  Hansell 
(Editorial,  Phila.  Polyclinic,  '97). 

Attention  called  to  effects  of  chloride 
of  zinc  upon  cases  of  pneumococcic  con- 
junctivitis.    Simple  instillation  of  a  Vi 
of  a  1-per-cent.  solution  of  this  salt  gener- 
ally causes  the  pneumococci  to  disappear 
from  the  sac;  and,  if  upper  lid  be  everted 
so  as  to  bring  remedy  into  upper  retro- 
tarsal  fold  as  well  as  lower,  a  few  appli- 
cations  almost   always   cure   the   worst 
cases.      H.    Gilford    (Archives    of    Oph., 
Nov.,  '98). 
In  the  severer  forms  of  conjunctivitis, 
when  there  is  a  purulent  inflammation 
or  an  exudate,  ice  is  the  sovereign  rem- 
edy.   When  employed  in  the  manner  in- 
dicated, disastrous  results  are  not  to  be 
feared. 

The   direct   application   of  ice   to   the 
lids  affords  the  best  means  of  getting  rid 
of  the  chemosis  and  oedema  of  both  lids 
and   conjunctiva.     Foucher    (Annals    of 
Ophthal.  and  Otol.,  Jan.,  '9.3). 
At  the  commencement  of  the  disease 
the  board-like  swelling  of  the  disease  is, 
doubtless,  one  of  the  chief  causes  of  py- 
rexia, and,  as  the  swelling  and  indura- 
tion prevent  the  cold  from  gaining  access 
to  the  eye,  it  is  necessary  that  the  treat- 
ment should  be  energetic  and  prolonged. 
The    compresses,    therefore,    should   be 
maintained  night  and  day  in  such  cases, 
and  should  only  be  desisted  from  when 
a  corneal  ulcer  threatens  or  the  secre- 
tion becomes  excessive.    If  either  of  these 
two  contingencies  should  arise,  the  ice- 
compress  should  at  once  be  substituted 
by  the  hot  application,  these  being  per- 
sisted in  for  fifteen  minutes  every  two 
or  three  hours.    The  hot  water  will  re- 
lieve engorgement  of  the  corneal  circula- 
tion indiicf.'d  ])y  tbo  intense  chemosis  of 


the  bulbar  conjunctiva,  and  favor  resolu- 
tion of  the  cornea. 

In  the  treatment  of  all  forms  of  con- 
junctivitis nitrate  of  silver  occupies  a 
leading  position,  the  strength  of  the  so- 
lution employed  being  proportionate  to 
the  intensity  of  the  inflammation  and  the 
quantity  of  the  secretion.  In  the  early 
stages,  where  the  discharge  is  mucoid  in 
character,  it  should  be  employed  in  the 
strength  of  from  2  to  4  grains  to  the 
ounce,  and  later,  i.e.,  when  the  discharge 
has  assumed  more  of  a  purulent  char- 
acter, from  10  to  20  grains  to  the  ounce. 

It  is  always  best  to  apply  the  silver 
directly  by  means  of  a  swab,  and  when 
the  stronger  solutions  are  employed  it 
should  always  be  neutralized  bj'  means 
of  sodium  chloride.  If  corneal  ulcer  oc- 
cur, atropine  should  be  at  once  instilled 
into  the  eye.  Many  discontinue  the  ap- 
plication of  the  silver  as  soon  as  this 
complication  occurs,  but  if  the  discharge 
be  very  marked  and  care  be  taken  to  ap- 
ply the  silver  in  the  manner  just  di- 
rected, it  will  usually  be  found  to  exer- 
cise a  most  advantageous  action  upon  the 
course  of  the  disease. 

Follicular  Conjunctivitis. 

Definition. — Follicular  conjunctivitis 
is  a  form  of  catarrhal  conjunctivitis  at- 
tended by  a  great  development  of  the 
lymph-follicles. 

Symptoms. — The  inflamed  follicles  ap- 
pear as  oval,  pinkish  prominences  the 
size  of  a  pin-head,  in  the  retrotarsal  folds, 
especially  the  lower.  They  may  be  very 
numerous  and  may  be  arranged  in  paral- 
lel rows.  In  a  proportion  of  the  cases 
they  are  but  few  in  number,  and  are 
scattered  over  the  conjimctiva.  There  is 
some  photophobia  and  inability  to  do 
near  work  for  any  length  of  time. 

Etiology. — Follicular  conjunctivitis  is 
frequently  seen  in  epidemic  form  in 
schools   and    asylums,    esf>ccially    where 


CONJUNCTIVA.     VERNAL  CONJUNCTIVITIS. 


283 


many  scholars  are  massed  together,  scrof- 
ulous subjects  being  particularly  prone 
to  be  affected.  As  there  are  frequently 
no  subjective  symptoms,  the  physician  is 
often  the  first  to  discover  the  presence 
of  the  follicles. 

Follicular  catarrh  is  frequently  noted 
among  school-cliildren  who  do  not  com- 
plain of  their  eyes;  confusion  may  arise 
from  confounding  this  innocuous  inflam- 
mation   with    the    dangerous    trachoma. 
H.  Cohn  (Berliner  klin.  Woch.,  June  20, 
'98). 
Pathology. — The  follicles  consist  of  a 
mass  of  round  cells,  identical  with  the 
lymphoid    stroma    of    the    conjunctiva. 
There  is  no  capsule,  and  the  epithelium 
is  unaffected.    In  the  acute  form,  when 
the  secretion  is  abundant,  the  affection 
is  contagious;    but,  when  there  is  but 
little  discharge,  the  follicles  lie  hidden 
in  the  cul-de-sac  without  giving  rise  to 
any  acute  symptoms,  and  contagiousness 
is  not  to  be  feared. 

The  disease  is  one  of  childhood  and 
adolescence,  and  may  be  associated  with 
acute  or  chronic  catarrh,  but  usually  with 
the  latter.  The  follicles  disappear  to- 
tally after  a  time;  so  that  the  prognosis 
is  favorable,  notwithstanding  the  chro- 
nicity  of  the  process  and  its  tendency  to 
relapse,  which  serves  to  differentiate  the 
disease  from  trachoma,  with  which  it 
bears  a  close  resemblance. 

Treatment. — Treatment  is  the  same  as 
for  catarrhal  conjunctivitis,  with  the  ad- 
ditional indication  of  bringing  about  the 
disappearance  of  the  follicles.  This  is 
best  accomplished  by  insufflations  of 
iodoform,  aristol,  or  calomel.  In  stub- 
born cases  excision  or  expression  of  the 
follicles  has  been  recommended.  The 
hygienic  surroundings  should  be  bet- 
tered, if  need  be,  the  health  of  the  pa- 
tient attended  to,  and  all  near  work  pro- 
hibited. All  errors  of  refraction  should 
be  carefully  corrected  under  atropine. 


The  confusion  of  diagnosis  between 
follicular  conjunctivitis  and  trachoma 
has  led  to  an  equal  confusion  in  the 
treatment.  In  trachoma  the  essential 
element  is  lymphatic  hyperplasia,  and  the 
treatment  which  he  has  found  most  suc- 
cessful has  been  based  on  the  treatment 
of  lymphatic  enlargements  in  other  por- 
tions of  the  body.  First,  so  far  as  pos- 
sible the  cause  of  irritation,  whether 
chemical,  mechanical,  or  bacterial,  should 
be  removed.  This  often  involves  not 
only  frequent  irrigations  of  the  con- 
junctiva with  boric  acid  solution,  but  we 
should  consider  the  physical  condition 
and  surroundings  of  the  child.  Cod- 
livcr-oil  and  iodide  of  iron  are  valuable 
internally.  Locally,  on  alternate  days, 
he  has  found  a  combination  of  ichthyol, 
15  minims  (1  cubic  centimetre);  tinct- 
ure of  iodine,  1  drachm  (4  grammes)  ; 
gh'cerin,  1  ounce  (31  grammes),  to  be 
of  value.  On  the  other  days  an  instil- 
lation of  1  drop  of  the  following  com- 
bination may  be  made  at  home:  Zinc 
sulphate,  1  grain  (0.06  gramme)  ;  wine 
of  opium,  8  minims  (0.5  cubic  centime- 
tre);  water,  Vj  ounce  (15.5  cubic  cen- 
timetres). Alger  (Med.  Record,  Jan. 
24,  1903). 

Vernal  Conjunctivitis. 

Definition. — Vernal  conjunctivitis  is  a 
chronic  catarrhal  inflammation  of  the 
conjunctiva,  usually  occurring  in  chil- 
dren and  adolescents,  which  is  attended 
with  the  formation  of  characteristic  le- 
sions in  the  pericorneal  and  palpebral  tis- 
sues. 

Symptoms. — The  changes  at  the 
margin  of  the  cornea  consist  in  an  ac- 
cumulation of  the  conjunctival  epithe- 
lium with  hypertrophy  of  the  under- 
lying connective  tissue.  This  gives  rise 
to  large,  reddish-gray  prominences,  which 
may  readily  be  seen.  Although  located 
in  the  palpebral  fissure,  these  may  ex- 
tend for  some  little  distance  into  the 
corneal  tissue;  or  surround  the  entire 
cornea.  The  tarsal  conjunctiva  is  thick- 
ened in  the  neighborhood  of  the  diseased 


284 


COXJUNCTI^'A.     PURULENT  CONJUNCTIVITIS. 


area;  its  papilla  are  enlarged  and  present 
a  characteristic  mammillated  appear- 
ance. When  the  lids  are  first  everted, 
the  conjunctiva  is  covered  with  a  fine, 
bhiish-white  haze,  which  resembles  a 
layer  of  milk.  At  the  height  of  the 
process  there  is  profuse  lacrymation,  hut 
rarely  any  discharge.  Considerable  pho- 
tophobia is  complained  of. 

The  disease  usually  becomes  worse 
upon  the  approach  of  spring,  the  eyes 
being  comparatively  free  from  irritation 
in  the  winter.  It  is  quite  rare  and  gen- 
erally affects  males,  being  essentially  a 
disease  of  childhood  and  adolescence. 
The  prognosis  is  good,  although  the  dis- 
ease runs  a  very  chronic  course  and  may 
persist  from  ten  to  twenty  years.  It 
finally  disappears,  however,  leaving  no 
trace,  except  in  rare  cases,  in  which  a 
faint  haze  may  remain  on  the  cornea. 

Etiology. — The  disease  frequently  oc- 
curs in  malarial  subjects  of  both  sexes, 
and  is  at  times  seen  in  women  with  ir- 
regular catamenia.  The  primary  cause 
is  unknown. 

Treatment. — The  disease  is  incurable, 
and  palliation  of  the  acute  symptoms 
represents  all  that  can  be  done.  Van 
Milligen,  who  has  had  excellent  oppor- 
tunities to  study  the  disease  in  Constanti- 
nople, where  it  occurs  more  frequently 
than  elsewhere,  has  employed  a  solution 
of  acetic  acid,  1  to  20  grains  to  the 
ounce,  with  marked  benefit.  I  have  ob- 
tained excellent  results  from  the  same 
remedy. 

In  vernal  conjunctivitis,  applications 
of  nitrate  of  silver  or  sulphate  of  copper 
are  not  always  indicated,  and  do  good 
only  when  the  stringy,  inuco-punilcnt  se- 
cretion is  very  abundant.  In  the  peri- 
corneal form  the  best  treatment  is  mass- 
age of  the  cornea  with  mercurial  oint- 
ment, made  up  with  lanolin.  Darier 
(Annals  of  Ophth.,  July,  '97). 

Ab  there  is  no  discharge,  the  disease 


is  not  really  a  catarrh,  and  does  not  de- 
mand the  same  treatment  as  this  class  of 
cases.  The  eyes  should  be  kept  clean 
with  a  lO-grain-to-the-ounce  solution  of 
boric  acid;  dark  glasses  should  be  pre- 
scribed to  protect  the  eyes  from  the  light 
and  other  irritants,  such  as  dust,  smoke, 
etc.  If  there  is  much  pericorneal  in- 
jection, a  weak  mydriatic  should  be  pre- 
scribed: either  atropine  in  small  doses 
or  homatropine.  Iced  compresses  dimin- 
ish the  vascularity  and  alTord  marked 
relief.  Arsenic,  quinine,  and  iron  should 
be  administered  internally. 

Extirpation  of  the  hypertrophied  pa- 
pillaa  by  electrolysis,  and  obliteration  of 
the  superficial  vessels  supplying  the 
growth  in  the  limbus,  have  been  resorted 
to  with  good  results. 

Purulent  Conjunctivitis. 

Definition. — Purulent  conjunctivitis  is 
an  acute,  contagious  inflammation  of  the 
conjunctiva  caused  by  infection  with 
gonorrhoeal  virus,  and  attended  by  a 
copious,  purulent  discharge.  It  is  one 
of  the  most  dangerous  and  virulent  dis- 
eases of  the  eye.  The  contagion  is  car- 
ried by  micro-organisms,  the  gonococci 
of  Neisser,  which  appear  not  only  in  the 
pus,  but  also  in  the  superficial  layers  of 
the  conjunctiva  itself.  The  gonococci 
may  be  found  in  isolated  groups,  either 
in  the  pus-cells  or  epithelial  cells,  and 
their  virulence  depends  upon  the  severity 
of  the  urethral  disease  at  the  time  of 
infection;  the  more  violent  the  latter, 
the  greater  the  ocular  inflammation. 

Purulent  conjunctivitis  may  be  pro- 
duced during  any  stage  of  the  uretliral 
disease,  but  about  the  third  week  of  the 
existence  of  the  latter  is  the  most  danger- 
ous period,  the  discharge  being  then  very 
copious,  thick,  and  noxious.  The  dis- 
charge from  a  gleet  may,  however,  give 
rise  to  severe  and  even  destructive  gonor- 
rheal ophthalmia. 


CONJUNCTIVA.     GONORRHCEAL  OPHTHALMIA.     SYMl'TOMS. 


285 


According  as  the  afTection  occurs  in 
adults  or  infants,  it  is  called  gonorrhaeal 
ophthalmia  or  ophthalmia  neonatorum. 

Not  all  forma  of  diplocoeei  decoloring 
by  Gram's  stain  are  gonoeocei,  and  are 
not,  therefore,  due  to  tlie  gonococeua  in 
all  cases  of  inflanimiition  of  the  con- 
junctiva in  which  they  are  found.  In 
fact,  as  this  membrane  is  exposed,  it 
is  quite  possible  that  other  forms  of 
infection  occur.  A.venfcld  (Miinchener 
nied.  Wochen.,  Jan.  13,  1003). 

Gonorrhoeal  Ophthalmia. 

Definition. — Purulent  or  gonorrhoeal 
ophthalmia  is  a  specific  purulent  in- 
flammation of  the  conjunctiva  charac- 
terized by  great  swelling  of  the  lids  and 
conjunctiva,  and  by  copious  secretion 
of  contagious  pus,  presenting  a  marked 
tendency  to  destruction  of  the  cornea. 

Symptoms. — The  period  of  incubation 
varies,  according  to  the  intensity  of  the 
contagion,  from  a  few  hours  to  three 
days. 

At  first  the  signs  of  a  simple  catarrhal 
conjunctivitis  may  alone  be  present,  but 
soon  the  lids  become  red  and  so  tumefied 
and  tense  that  the  patient  is  no  longer 
able  to  open  them.  The  palpebral  con- 
junctiva and  retrotarsal  folds  also  be- 
come intensely  red  and  swelled,  and  the 
former  is  often  speckled  with  hoemor- 
rhages.  The  membrane  becomes  hard 
and  granular,  owing  to  an  infiltration  of 
seroplastic  lymph  into  its  substance.  The 
bulbar  conjunctiva  soon  becomes  simi- 
larly swelled,  forming  a  hard  rim  about 
the  cornea.  The  discharge  is  at  first 
watery  and  sanious,  but  soon  changes  to 
a  yellow  or  greenish-yellow  pus.  The 
eye  is  painful  to  the  touch,  and  there  is 
intense  pain  in  the  eye  and  temple.  The 
constitutional  symptoms  are  often  severe, 
the  patients  being  generally  in  a  weak 
and  feeble  condition.  Slight  fever  is  also 
present  in  some  cases. 

This  stage — that  of  infiltration — lasts 
about  three  davs,  when  the  disease  attains 


its  height.  The  lids  then  become  less 
tense,  the  conjunctiva  softer,  and  a  copi- 
ous purulent  secretion  follows.  After  a 
week  the  discharge  gradually  declines, 
the  tissues  undergo  restoration,  and,  at 
the  end  of  four  to  six  weeks,  beyond  a 
condition  of  chronic  inflammation  of  the 
conjunctiva,  which  persists  many  weeks, 
the  parts  resume  their  normal  appear- 
ance.   Cicatrices  rarely  follow. 

At  times  the  disease  assumes  more  of 
a  subacute  type.     All  the  signs  of  in- 
flammation are  then  less  severe,  the  pal- 
pebral conjunctiva  being  alone  afllected, 
and  it  is  often  only  possible  to  diagnose 
these  cases  from  catarrh  of  the  conjunc- 
tiva   by    a    microscopical    examination. 
AVhen  the  disease  is  particularly  virulent, 
it  may  simulate  the  croupous  tj'pe,  a  false 
membrane  being  formed,  which  gives  the 
conjunctiva  a  yellowish-gray  appearance. 
In   the   prophylaxis   of  purulent   con- 
junctivitis,   which    is    generally    gonor- 
rhceal  in  character,  great  care  must  be 
taken  not  to  contaminate  the  eye  with 
pus   from    the   urethra    or    vagina.      In 
purulent    ophthalmic    neonatorum    the 
eyes  of  every  infant  are  first  washed 
outside  with  mercury  cyanide  or  bichlo- 
ride, 1  to  20,  and  a  drop  of  a  2-per-cent. 
silver  nitrate  solution   is  dropped  into 
each    eye.     This,    CredC's    method,    has 
greatly  decreased  the  number  of  cases 
of   gonorrhoeal    ophthalmia    in    infants. 
A.  Trousseau    (La   Presse   Mi-d.,  March 
2G,  1002). 
Complications. — The  chief  danger  in 
purulent  conjunctivitis  is  the  implica- 
tion of  the  cornea.    It  results  from  the 
pressure  of  the  swelled  tissues;   the  cor- 
rosive action  of  the  secretion,  including 
the  invasion  of  the  gonoeocei;  and  direct 
continuity  of  inflammation  to  the  sub- 
stance of  the  cornea. 

At  first  the  cornea  may  look  dull  and 
slightly  clouded;  but  soon  circumscribed 
areas  of  grayish  infiltration  appear,  which 
soon  become  more  dense  and  yellow,  and 
then  form  ulcers.     The  ulceration  u?u- 


2S6 


COXJUXCTIVA.    GOXOKKHCEAL  OPHTHALMIA.    TKEATMENT. 


ally  occurs  at  the  limbus,  and  may  lead 
to  rapid  perforation.  In  many  instances 
this  is  a  relatively-farorable  result,  as 
fiirther  infiltration  of  the  cornea  is  fre- 
quently prevented  thereby.  In  other 
cases,  however,  the  infiltration  may  form 
at  the  margin  of  the  cornea  and  extend  a 
considerable  distance  around  its  circum- 
ference, giving  rise  to  a  marginal  ring 
ulcer.  Sloughing  of  a  great  portion  or 
even  the  whole  of  the  cornea  usually  fol- 
lows, and  the  eye  is  usually  lost. 

The  ulceration  may  also  occur  at  the 
centre  of  the  cornea,  when  the  whole 
cornea  becomes  opaque.  As  a  rule,  the 
greater  the  severity  of  the  conjunctivitis, 
the  greater  the  liability  to  corneal  in- 
volvement, especially  if  the  bulbar  con- 
junctiva be  much  chemosed.  As  a  rule, 
also,  the  earlier  the  corneal  ulcers  form, 
the  more  likely  are  they  to  result  seri- 
ously. 

Corneal  ulceration  usually  appears  on 
about  the  third  day,  but  this  depends 
upon  the  severity  of  the  inflammation; 
in  a  certain  number  of  cases  it  does  not 
appear  until  late  in  the  disease. 

Iritis  may  supervene  when  the  ulcera- 
tion has  extended  to  the  deeper  layers  of 
the  cornea  or  when  perforation  has  oc- 
curred. It  generally  gives  rise  to  great 
ciliary  neuralgia,  photophobia,  and  lac- 
rymation. 

The  inflammation  may  extend  from 
the  iris  to  the  other  ocular  tissues,  and  a 
panophthalmitis  be  set  up. 

Prognosis  depends  entirely  upon  the 
degree  of  implication  of  the  bulbar  con- 
junctiva, for,  if  this  be  much  chemosed, 
corneal  ulceration  will  probably  occur 
and  vision  be  seriously  compromised. 

Etiolo^.  —  Gonorrhoea!  ophthalmia 
arises  through  infection  with  gonorrhoeal 
puB  alone,  the  virus  being  conveyed  di- 
rectly from  the  genitalia  to  the  eyes,  or 
from  a  diseased  eye  of  another  person,  or 


from   the    patient's   fellow-eye    by    the 
hand,  handkerchief,  etc. 

The  serious  ophtbaliuias  are  those  pro- 
duced by  streptococci  or  by  au  associa- 
tion of  streptococci  and  gonococci,  or  by 
the  combination  of  these  two  with  others. 
The  gonococci,  when  alone,  are  compara- 
tively harmless  (?)  and  yield  to  treat- 
ment, which  should  be  prompt  and  vig- 
orous, consisting  of  copious  irrigations 
with  potassium  permanganate,  boric 
acid,  and  cauterization  with  silver  ni- 
trate. This  combination  acts  on  all  the 
various  species  of  microbes  which  may 
be  producing  the  ophthalmia.  Chartres 
(Arch.  Clin,  de  Bordeaux,  Dec,  '90). 

Case  of  gonorrhceal  conjunctivitis  sec- 
ondary to  a  gonorrhoea  induced  by  inter- 
course during  menstruation.  Formalin 
proved  effective.  Hansell  (Editorial, 
Phila.  Polyclinic,  '97). 

There  is  a  direct  proportion  between 
ease  of  transportation  and  a  low  rate  of 
blindness,  while  a  higher  ratio  is  to  be 
expected  where  travel  is  poor  and  incon- 
venient.    L.   Howe    (N.   Y.   Med.   Jour., 
June  26,  '97). 
Sequels  are  the  result  of  corneal  in- 
volvement, for  the  conjunctiva  is  usually 
restored  to  a  healthy  condition;  but,  in 
the  event  of  the  corneal  ulceration,  all 
eventualities  are  possible;  from  a  slight 
degree  of  opacity,  on  the  one  hand,  to 
adherent  leucoma,  panophthalmitis,  or 
even  atrophy  of  the  globe,  on  the  other. 
Treatment." — The  chief  indication  in 
the  treatment  consists  in  carefully  and 
frequently  freeing  the  eyes  of  the  copious 
secretion;  for  this  purpose  bichloride-of- 
mercury  or  boric-acid  solutions  should  be 
employed  very  often.    To  do  this  prop- 
erly will  require  the  constant  care  of  two 
intelligent     attendants.       The     patient 
should  be  put  to  bed,  and,  if  but  one  eye 
be  afl'ected,  its  fellow  should  be  carefully 
protected.     For  this  purpose  the  device 
of  Buller  answers  admirably.    This  con- 
sists in  a  watch-glass  held  in  place  before 
the  eye  by  strips  of  adhesive  plaster.    It 
should    be    removed    every    forty-eight 


CONJUNCTIVA.  GONOKRHCEAL  OPHTHALMIA.  TREATMENT. 


287 


hours  and  the  eye  thoroughly  cleansed 
with  a  solution  of  boric  acid.  The  sur- 
geon should  warn  the  patient  of  the 
danger  of  carrying  any  of  the  urethral 
discharge  to  the  eyes  and  should  caution 
the  nurses  about  exercising  the  most 
punctilious  cleanliness  as  regards  their 
hands,  and  care  in  the  use  of  towels, 
handkerchiefs,  etc. 

It  is  the  duty  of  every  physician  at- 
tending a  case  of  purulent  conjunctivitis 
to  warn  tliose  living  with  tlie  patient 
of  the  very  contagious  nature  of  the  dis- 
charge from  the  eyes,  and,  where  pos- 
sible, to  isolate  both  the  patient  and  the 
nurse  in  charge.  Johnson  (Times  and 
Register,  Sept.  IG,  '93). 

In  gonorrhoeal  conjunctivitis,  if  only 
one  eye  is  affected,  the  other  should  be 
hermetically  sealed.  The  diseased  organ 
should  be  washed,  at  least  every  half- 
hour,  with  a  solution  of  mercury  bichlo- 
ride, 1  to  5000,  or  a  saturated  solution 
of  boric  acid,  and,  every  four  hours,  the 
conjunctival  cul-de-sacs  should  be  thor- 
oughly cleaned  with  pyrozone.  In  ad- 
dition, ice-compresses,  to  be  changed 
every  few  minutes,  should  be  applied  con- 
stantly, day  and  night,  in  the  first  stage. 
When  there  is  severe  pain  and  swelling, 
relief  may  be  afforded  by  canthotomy, 
slitting  the  conjunctiva,  or  leeching  the 
temples.  In  the  second  stage,  when  the 
conjunctiva  has  become  velvety,  the  care- 
ful application  of  a  3-pcr-cent.  solution 
of  silver  nitrate  is  best  treatment.  After 
its  use  the  conjunctiva  should  be  thor- 
oughly cleansed  with  a  saturated  solu- 
tion of  common  salt.  In  the  third  stage, 
when  acute  inflammation  has  completely 
subsided,  the  silver  is  replaced  by  crys- 
tals of  zinc  or  copper.  In  all  stages 
atropine  should  be  used  when  there  is 
any  appearance  of  haziness  or  ulceration 
of  the  cornea.  A.  T.  Haight  (Chicago 
Clinic,  xiii,  p.  317,  IBOO). 

Great  care  should  always  be  exercised 
in  washing  the  eyes  of  these  cases,  as  the 
pus  frequently  spurts  out  like  a  jet  when 
the  lids  are  separated. 

If  the  swelling  of  the  lids  prevents 
ready  access  to  the  cul-de-sac,  canthop- 


lasty  should  be  performed,  as  this  pro- 
cedure not  only  gives  access  to  the  cul- 
de-sacs,  but  lessens  the  pressure  of  the 
lids,  and  gives  room  for  the  infection  to 
spread. 

In  the  first  stage,  ice-compresses 
should  be  applied  constantly  night  and 
day  and  changed  every  few  moments.  In 
robust  subjects  or  when  there  is  intense 
initial  pain  or  swelling,  marked  relief 
may  often  be  obtained  by  leeching  the 
temples. 

In   the   treatment   of   fifteen   cases   of 
purulent  ophthalmia  good  results  were 
obtained    by    the    mild    and    antiseptic 
method  (silver,  5  grains;  corrosive  sub- 
limate,  I   to  5000).     Campbell    (Harper 
Hosp.  Bull.,  Detroit,  Dec,  '93). 
In  the  second  stage,  when  the  con- 
junctiva has  become  velvety  and  the  dis- 
charge purulent,  the  conjunctiva  should 
be  touched  with  silver  nitrate  (15  to  20 
grains  to  the  ounce  of  water),  to  reduce 
the  swelling  and  the  amount  of  secretion. 
The  silver-nitrate  solution  should  be  ap- 
plied by  the  surgeon  to  the  conjunctiva 
of  the  everted  lids  and  then  neutralized 
with  a  saturated  solution  of  common  salt, 
as  directed  in  catarrhal  conjunctivitis. 

Great  importance  of  reaching  all  parts 
of  the  conjunctiva  with  3-per-cent.  ni- 
trate-of-silvcr  solution  in  gonorrhoeal 
ophthalmia.  Abadie  (Bull.  Gen.  de  Th6r., 
Jan.  15,  '95). 

When  cornea  implicated,  quinine  sul- 
phate, 4  grains  to  1  ounce,  with  smallest 
possible  amount  of  sulphuric  acid;  to  be 
used  in  intervals,  but  not  as  a  .substitute 
for  silver  nitrate.  Tweedy  (Practitioner, 
Mar.,  '95). 

Purulent  ophthalmia  and  dacryocys- 
titis successfully  treated  by  potassium- 
permanganate  solutions,  1  per  cent,  to  10 
per  cent.  Case  of  diphtheritic  conjunc- 
tivitis treated  by  crude  petroleum-oil. 
Vian  (Recueil  d'Oplital.,  Aug.,  '95). 

Protargol  in  lO-per-cent.  solution  used 
for  personal  application  in  purulent  con- 
junctivitis and  5-per-cent.  solution  for 
use  at  home.  Furst  (Fortsch.  d.  Med., 
No.  4,  '98). 


288 


CONJUNCTIVA.  OPHTHALMIA  NEONATORUM.  SYMPTOMS. 


Protargol  in  5-per-cent.  solution  is 
practically  a  specific  against  purulent 
conjunctivitis.  A.  Darier  (Ophtb. 
Klinik.,  Nov.  7,  "OS). 

A  10-per-cent.  ointment  of  the  milky 
juice  of  the  cassaripe  plant  is  valuable  in 
purulent  disease  of  the  conjunctiva  ac- 
companied by  corneal  ulcers.     S.  D.  Ris- 
ley  (Phila.  Med.  Jour.,  Oct.  29,  '98). 
It  is  best  to  delay  the  application  of 
silver  so  long  as  the  conjunctiva  is  hard 
and    infiltrated    and    the    discharge    is 
watery.      A    croupous    membrane    also 
contra-indicates  its  use. 

In  the  third  stage,  when  the  signs  of 
chronic  conjunctivitis  appear,  the  silver 
should  be  substituted  by  crystals  of  zinc 
and  copper,  but  these  should  only  be  em- 
ployed when  the  cornea  is  quite  free  from 
all  signs  of  acute  inflammation  and  ulcer- 
ation.   During  the  entire  course  of  the 
disease,  the  cornea  should  be  carefully 
inspected,  and,  at  the  first  appearance  of 
ulceration,  atropine  should  be  instilled. 
This  drug  frequently  serves  a  double  pur- 
pose in  combating  any  existing  iritis,  as 
well   as   the   corneal   involvement.     If 
corneal  ulceration  be  present,  great  care 
must  be  exercised  in  making  the  applica- 
tions of  silver  to  the  everted  lids,  as  press- 
ure on  the  globe  might  cause  rupture  of 
the  ulcer.    Care  should  also  be  exercised 
to  prevent  the  silver  coming  in  contact 
with  the  infiltrated  cornea. 
Ophthalmia  Neonatorum. 
Definition.— This  is  a  purulent  inflam- 
mation of  the  conjunctiva  occurring  in 
the    newborn,    characterized    by    great 
swelling  of  the  lids  and  conjunctiva,  and 
the  copious  discharge  of  contagious  pus. 
This  is  one  of  the  most  frequent  of 
eye  diseases,  and  is  responsible  for  more 
cases  of  blindness  than  any  other  affec- 
tion, the  statistics  showing  that  from  30 
to  GO  per  cent,  of  the  inmates  of  the 
different  blind-asylums  throughout  the 
country  owe  their  infirmity  to  its  rav- 
ages.    Of  the  three  hundred  thousand 


blind  in  Europe,  thirty  thousand  were 
rendered  so  by  ophthalmia  neonatorum. 
Symptoms. — The  disease  usually  ap- 
pears on  the  second  or  third,  more  rarely 
on  the  fourth  or  fifth,  day  after  birth. 
In  the  latter  case,  however,  it  is  probable 
that  infection  is  carried  to  the  eyes  after 
birth,  either  from  the  mother  or  the 
nurse  or  some  other  person  suffering 
from  gonorrhea. 

The  active  sj-mptoms  are  the  same  as 
the  gonorrhceal  conjunctivitis,  except 
that  they  are  not  so  severe.  The  swelling 
of  the  lids  is  not  so  great  and  the  secre- 
tion is  less  copious.  The  bulbar  chemosis 
does  not  attain  such  a  high  degree,  and 
corneal  complications  are  not  so  frequent 
nor  so  serious. 

The  disease  may  occur  in  a  severe  type, 
with  a  tendency  to  invade  the  cornea; 
or  it  may  run  a  milder  course,  without 
corneal  complication. 

lu  the  mild  form  of  conjunctivitis  in 
the  newborn  there  is  little  pus,  much 
lacrymation,  and  moderate  palpebral 
injection,  although  the  pneuiuococeus  is 
present.  Parinaud  {La  Mfd.  Mod.,  Jan. 
19,  ■95). 

Bacteriological  examination  of  100 
cases  of  infantile  ophthalmia,  clinically 
ranging  from  a  simple  catarrh  to  a  se- 
vere blennorrha?a.  The  following  organ- 
isms were  found:  Gonococci,  pneumo- 
cocci,  and  streptococci ;  possibly  in  some 
cases  staphylococcus  aureus  and  bacillus 
coli.  The  etiological  importance  of 
other  organisms  was  doubtful.  The  se- 
vere cases  of  blennorrhcea  were,  for  the 
most  part,  caused  by  gonococci;  but 
there  occurred  cases  in  which,  in  spite 
of  most  careful  examination,  gonococci 
were  not  found.  The  gonorrhojal  cases 
nlwaya  showed  clinically  certain  pecul- 
iarities. The  cases  without  gonococci 
were  never  complicated  by  corneal  ulcer, 
and  ran  a  much  shorter  and  milder 
course.  Also  cases  of  slight  and  medium 
severity  without  gonococci  showed  after 
a  few  days'  treatment  marked  lessoning 
or  disappearance  of  purulent  discharge, 
whereas  the  pus  of  gonorrlucal  in  nam- 


CONJUNCTIVA.    OPHTHALMIA  NEONATORUM.    PROPHYLAXIS. 


289 


mation  seldom  disappeared  under  two 
weeks.  Gonoeocci  were  the  cause  of  the 
inflammation  in  41  of  the  100  cases;  in 
25  of  these  the  alTeetion  was  severe.  In 
gonorrhoea!  cases  for  days  and  weeks 
after  pus  has  disappeared  gonoeocci 
may  be  found  in  the  conjunctival  sac; 
BO  that  the  use  of  silver  preparations 
must  be  continued  long  after  purulent 
discharge  has  ceased.  Groenouw  (Arch. 
f.  Ophthal.,  B.  lii,  p.  1,  1901). 

While  the  gonococcus  is  regarded  as 
the  sole  evoking  agent  of  gonorrhoea, 
it  is  not  the  sole  etiological  factor  in 
ophthalmia  of  the  newborn.  The  so- 
called  pseudogonococcus  has  been  al- 
leged to  be  one  of  the  causes  of  the  lat- 
ter, and  the  author  doubts  the  truth 
of  this  contention.  Schanz  (Deutsche 
med.  Wochon.,  Nov.  5,  1903). 

The  prognosis  depends  upon  the  state 
of  the  cornea  when  the  case  comes  under 
treatment.  If  this  be  uninvolved,  the 
chances  of  recovery  are  favorable. 

Study  of  forty  cases  of  ophthalmia 
neonatorum ;  average  duration  of  gonor- 
rhoeal  cases,  fifty-three  days;  average  du- 
ration of  non-gonorrha'al,  thirty-six  days. 
Francisco  (N.  Y.  Eye  and  Ear  Infirmary 
Reports.,  Jan.,  '95). 

Etiology. — The  origin  of  the  conta- 
gion is  the  morbid  vaginal  secretion,  the 
infection,  as  a  rule,  occurring  at  the  time 
of  birth  by  some  of  the  secretion  of  the 
vagina  being  transferred  to  the  lids  of 
the  infant  and  being  carried  into  the  eye 
the  first  time  that  the  child's  eyes  are 
opened. 

Twenty  per  cent,  of  all  cases  of  blind- 
ness are  found  in  youth,  and,  of  these, 
20  to  25  per  cent,  are  caused  by  blen- 
norrhoea  neonatorum.  In  85  per  cent,  of 
these  cases  the  afTcction  begins  within 
five  days  after  birth,  and,  if  immediately 
treated,  70  per  cent,  arc  cured.  Early 
corneal  complications  arc  the  gravest. 
Pflueger  (Coitcs.  fiir  Schweizer  Aerztc, 
Sept.  15,  '95). 

Catarrh  of  the  nc'vliorn  duo  to  nitrate 
of  silver  studied.  Results  of  300  cases 
treated  by  CrcdC's  method.     In  4  out  of 

2- 


100  there  was  no  reaction,  in  73  the  secre- 
tion had  disappeared  entirely  on  the  fifth 
day,  in  the  others  it  lasted  longer.  Irri- 
tation was  not  caused  so  much  by  in- 
creasing the  number  of  drops  as  by  using 
it  on  successive  days.  .Small  and  ill- 
developed  children  are  more  sensitive  to 
argentic  nitrate  than  healthy  ones. 
Catarrh  for  the  first  twenty-four  hours 
is  usually  aseptic,  and  after  that  septic. 
Only  1  out  of  300  cases  had  gonorrhoea! 
conjunctivitis.  H.  Cramer  (Centralb.  f. 
Gyniik.,  Mar.  4,  '99). 

Prophylaxis. — The  great  aim  should 
be  the  prevention  of  contagion  during 
birth.  If  this  be  done  there  is  no  disease 
in  which  prophylactic  measures  are  so 
efficacious  and  the  results  obtained  so 
gratifying.  Since  the  adoption  by  oph- 
thalmologists of  adequate  measures,  the 
proportion  of  cases  of  ophthalmia  ne- 
onatorum has  been  reduced  from  7.5  per 
cent,  to  0.5  per  cent.  Vaginal  antisep- 
tics should  be  employed  before  labor. 
Immediately  the  child  is  born,  the  lids 
should  be  wiped  with  a  piece  of  lint 
saturated  in  bichloride  solution  (1  to 
8000). 

After  the  child  has  been  washed,  dur- 
ing which  care  should  be  taken  that  none 
of  the  water  is  permitted  to  gain  access 
to  the  conjunctival  sac,  a  drop  of  a  2-per- 
oent.  solution  of  silver  nitrate  should 
be  dropped  into  each  eye.  The  solution 
of  silver  in  this  strength  excites  consid- 
erable irritation,  and  while  its  applica- 
tion should  always  be  insisted  upon  in 
hospitals  and  the  lilvc,  in  private  practice, 
where  no  gonorrha?al  contagion  is  sus- 
pected, the  douche  before  labor  and  the 
cleansing  of  the  lids  by  bichloride  solu- 
tion, followed  by  a  careful  douching  of 
the  conjunctival  cul-de-sac  with  boric 
acid  will  suffice. 

In  making  the  applications  the  child 
should  be  laid  on  its  back  and  its  head 
placed  between  the  knees  of  the  physi- 
cian, while  an  assistant  seated  in  front 
19 


290 


COXJUNXTIVA.  OPHTHALMIA  NEONATORUM.  TREATMENT. 


should  hold  its  body  in  his  lap  and  se- 
cure the  hands.  The  lids  should  then  be 
gently  separated  by  pulling  on  the  skin 
of  the  eyelids  above  the  upper  and  below 
the  lower  tarsus,  and  complete  eversion 
of  both  lids  performed. 

Propensity  of  newborn  infants  to  rub 
their  eyes  with  their  fists;  source  of  con- 
tagion— face  and  hands,  as  well  as  eyes — 
to  be  cleansed  at  birth.  Ayers  (Amer. 
Jour.  Med.  Sci.,  June,  '95). 

Theory  advanced  in  favor  of  the  method 
of  Crede,  that  of  direct  inoculation  of 
the  eyes  of  infants  by  the  vaginal  secre- 
tions, opposed.  It  is  contended  that  the 
lids  are  rolled  inward  to  cover  and  pro- 
tect the  eyes  until  after  birth,  and  that 
when  they  are  opened  the  portions  hav- 
ing any  secretion  from  the  vagina  upon 
them  are  remote  from  the  edges  of  the 
lids.  Merely  rendering  the  lids  antiseptic 
is  enough;  instillation  of  silver  solution 
is  not  prophylactic.  A  piece  of  cotton 
dipped  in  1  to  100  mercury  cyanide 
should  be  applied  over  the  lids  to  dis- 
infect thoroughly  before  bathing,  and 
should  be  repeated  after  the  eyes  have 
been  washed.  De  Wecker  (Jour,  de  Clin, 
et  de  Ther.  Inf.,  No.  42,  '99). 

The  douche  fulfills  the  requirements 
of  cleanliness,  which  are  so  essential. 
Critical  case  referred  to  which  recovered 
under  systematic  irrigations  with  the 
douche  of  a  l-per-cent.  solution  of  boric 
acid.  In  this  and  other  cases  the  other 
well-known  methods  had  been  tried  and 
failed.  Holt  (Jour.  Amer.  Med.  Assoc, 
Jan.  .5,  1901). 

Treatment. — The  treatment  is  the 
same  as  has  just  been  given  under  the 
gonorrhceal  ophthalmia  of  adults,  with 
the  exception  that  the  protection  of  the 
sound  eye  and  the  application  of  com- 
presses are  not,  as  a  rule,  feasible. 

Gonorrliiual  conjunctivitis  in  fifty- 
Bfven  newborn  infants  treated  with 
calomel.  The  gonococcus  of  Neisser  was 
found  in  the  discharge  in  all  the  cases. 
The  conjunctival  mucous  membrane  hav- 
ing been  syringed  with  a  2-pcr-cent.  solu- 
tion of  boric  acid,  and  well  dried  witli 


absorbent  cotton,  was  dusted  with  calo- 
mel. One  day  after  the  first  application 
the  discharge  and  swelling  of  the  mucous 
membrane  diminished,  even  in  severe 
cases.  Sometimes  the  dusting  had  to  be 
repeated  two  or  three  times.  The  treat- 
ment lasted  only  for  a  week,  and  in 
neglected  cases  of  long  standing  not  more 
than  a  fortnight.  The  results  were  very 
satisfactory.  Pukalof  (Wratch,  No.  27, 
'97). 

In  purulent  ophthalmia  in  the  newborn 
the  lids  are  first  cleansed,  then  I-per-cent. 
to  2-per-cent.  solution  of  copper  sulphate 
applied;  5-per-cent.  ichthyol  salve  is  to 
be  used  three  times  daily.  Elze  (Woch. 
f.  Therap.  u.  Hyg.  d.  Auges.,  Nov.  II,  '98). 

Silver-nitrate  solutions  should  only  be 
used  in  the  later  stages  of  the  disease, 
after  the  intense  swelling  of  the  eyelids 
has  begun  to  subside  and  the  discharge 
is  more  purulent.  A  2-per-cent.  solution 
may  then  be  applied  to  the  conjunctival 
surface  and  neutralized  with  salt  solu- 
tion. Nothing,  however,  should  take 
the  place  of  the  constant  cleansing. 
Solutions  of  protargol  seem  less  reliable 
than  silver  nitrate.  The  edges  of  the 
eyelids  and  the  surrounding  skin  should 
be  protected  with  vaselin.  In  patients 
who  are  in  poor  physical  condition,  the 
application  of  heat  will  often  prove  bet- 
ter than  cold.  If  the  cornea  becomes 
hazy  and  a  small  ulcer  forms,  the  irri- 
gation should  be  continued  and  a  I-per- 
cent.  atropine  solution  applied  three 
times  a  day,  with  hot  applications.  In 
some  cases  of  marginal  ulceration  solu- 
tion of  eserine,  '/^  grain  to  the  ounce, 
may  be  used  every  four  hours,  but  with 
care.  In  adults,  if  the  disease  has  only 
afl'eeted  one  eye,  the  other  eye  should 
be  at  once  protected  by  covering  it  with 
a  small  pad  of  absorbent  cotton  and 
gauze.  C.  II.  Williams  (Boston  Med. 
and  Surg.  Jour.,  Feb.  7,  1901). 

The  best  resiilts,  as  shown  by  an  ex- 
tensive investigation,  were  obtained 
wlion  a  2-per-cent.  solution  of  silver 
nit-rate  was  used  immediately  after 
birth,  following  the  suggestion  of  CredS. 
Only  0.8.5  per  cent,  were  affected  with 
tlie  disease  when  this  solution  was  used. 
Almost  equally  as  good  results  were  ob- 
tained   from    a    l-per-cent.    solution    of 


CONJUNCTIVA.    GRANULAR  CONJUNCTIVITIS.     DEFINITION. 


291 


sublimate,  but  weaker  solutions  were 
attended  by  higher  percentages  of  oph- 
thalmia. Furthermore,  irritant  effects 
from  this  drug  are  so  rare  that  they  are 
hardly  worth  considering,  and  substi- 
tutes for  silver  nitrate  seem  to  be  un- 
necessary. Recently  protargol  in  20- 
per-cent.  solution  has  been  employed 
with  good  results,  and  it  is  claimed  that 
it  is  unirritating.  In  the  treatment  of 
this  affection  it  is  said  that  the  stage 
in  which  a  case  of  infantile  ophthalmia 
is  seen  should  be  its  worst  stage.  From 
the  time  when  applications  of  a  2-per- 
cent, solution  of  silver  nitrate  once 
every  twenty-four  hours  to  the  inner 
surface  of  the  everted  lids  are  begun  the 
condition  should  commence  to  improve. 
Cold  compresses  are  also  useful.  E.  T. 
Collins   (Practitioner,  April,  1902). 

Notwithstanding  the  application  of 
Crede's  method  there  are  still  a  large 
number  of  cases  of  blennorrhcea  in  the 
newborn.  This  method  was  applied  to 
902  children  born  in  the  clinic  for  women 
in  Berlin,  and  1.5  per  cent,  suffered  from 
blennorrhcea. 

The  clinic  for  diseases  of  women  in 
Gottingen  shows  better  results  with 
Crede's  method.  In  the  period  since 
1888  there  were  1917  births  in  which  no 
single  case  of  early  blennorrhcea  oc- 
curred, and  only  3  of  late  infection,  and 
all  of  these  were  slight.  Gonorrhoea  is 
a  frequent  disorder  in  the  maternity; 
in  a  series  of  cases  in  which  this  infec- 
tion was  carefully  looked  for  it  was 
found  present  in  nearly  2.5  per  cent. 

In  no  case  did  more  than  slight  con- 
gestion of  the  conjunctiva  follow  the  in- 
stillation of  nitrate  of  silver,  and  this 
only  when  2-per-cent.  solution  was  used. 
When  the  method  was  first  employed 
the  stronger  solution  was  used,  but  in 
the  last  928  children  a  1-per-cent.  solu- 
tion was  instilled.  The  most  important 
point  in  the  technique  is  to  instill  the 
solution  as  soon  after  the  child  is  born 
as  possible.  If  an  hour  has  passed,  it 
may  be  too  late  to  prevent  the  infection. 
It  is  probable  that  the  neglect  of  this 
latter  precaution  has  led  to  the  reported 
failures  in  other  clinics.  Hirsch  (Klin- 
isches  Jahrbuch,  Bd.  iii,  H.  3,  1902). 


Granular  Conjunctivitis  (Trachoma, 
Egyptian  Ophthalmia,  Miliary  Oph- 
thalmia) . 

Definition. — Granular  conjunctivitis  is 
an  inflammation  of  the  conjunctiva, 
characterized  by  the  hypertrophy  of  the 
tissues  and  by  the  development  of  small 
pinkish  prominences  or  granulations  on 
the  conjunctiva,  the  chief  tendency  of 
which  is  to  undergo  absorption  and  pro- 
duce serious  cicatricial  changes  in  the 
Uds. 

Although  it  was  generally  supposed 
that  the  disease  was  introduced  into 
Europe  from  Egypt  by  Xapoleon's  army 
in  179S,  it  was  subsequently  shown  that 
the  disease  had  actually  been  endemic 
in  Europe  several  centuries  before.  Ex- 
cellent descriptions  of  the  disease  were 
recorded  by  the  ancients,  and  measures 
adopted  by  them  for  its  relief  have  come 
to  light  again  in  our  own  day  under  the 
form  of  the  operation  of  scarification. 
Nevertheless,  to  Napoleon  is  due,  in  large 
measure,  the  propagation  of  the  disease, 
for  it  was  doubtless  owed  to  the  fre- 
quency with  which  his  armies  came  in 
contact  with  those  of  other  countries,  as 
well  as  with  the  ci-vil  population,  that 
the  disease  spread  so  rapidly  during  the 
first  part  of  the  present  century. 

The  Jews,  the  Irish,  the  inhabitants  of 
the  East,  and  the  Xorth  American  In- 
dians are  especially  liable  to  the  affection, 
while  negroes  are  practically  exempt. 

Geographically,  the  disease  occurs 
more  often  in  Arabia  and  Egj'pt,  while 
western  Europe  is  more  exempt  than 
eastern  Europe.  In  the  United  States 
it  affects  those  dwelling  in  tenement- 
houses,  and  is  associated  with  unhygienic 
surroundings  in  large  cities.  It  prevails 
in  the  Western  prairies,  and  is  found 
scattered  widely  over  the  country.  High 
altitudes  seem  to  render  a  certain  im- 
munitv  to  the  disease. 


292 


COXJU^'CTIVA.    GRAXULAE  COJTJXINCTIVITIS.    SYMPTOMS. 


Verification  of  the  law  established  by 
Chibret  concerning  the  immunity  given 
by  a  high  altitude.  A  certain  elevation 
above  the  sea-level  offers  the  best  con- 
ditions for  cure,  but  there  is  no  abso- 
lute immunity.  Sattler  (Kevue  G6n. 
d'Ophtal.,  Aug.,  '90). 

In   the   City   of  Mexico   trachoma   is 
very  rare.     The  hygienic  conditions   of 
the  lower  classes  being  of  the  very  worst, 
it  is  the  altitude  of  the  city  (6000  feet) 
that  renders  it  free  from  this  pernicious 
disease.    Race  has  nothing  to  do  with  the 
question,  as  there  are  many  foreigners 
living   in  the   city   who   are   alike   free 
from  any  visitation  of  the  inflammation. 
Chacon  (Gaeeta  Medica  de  Mexico,  June 
1,  '92). 
Symptoms. — There  is  a  great  difEer- 
ence  in  the  symptoms,  not  only  on  ac- 
count of  the  intensity  of  the  changes, 
but  also  from  the  rapidity  of  the  course 
of  the  disease.     The  signs  of  irritation 
are  greater,  the  quicker  the  course  of  the 
disease.     Usually,  the  irritation  symp- 
toms are  only  moderate,  but  slight  pho- 
tophobia, lacrymation,  and  pain  being 
complained  of. 

Xot  seldom  the  disease  is  so  insidious 
that  the  subject  does  not  know  of  its 
existence,  the  disturbance  in  vision  due 
to  corneal  complication  giving  the  first 
indication.  This  is  especially  the  case 
when  the  disease  occurs  in  eleomoscenary 
acute  trachoma.  Here  the  disease  begins 
with  marked  inflammatory  symptoms; 
the  lids  are  cedematous,  the  conjunctiva 
swollen,  and  there  is  a  rich  secretion  of 
pus. 

Granular  conjunctivitis  may  occur  in 
either  an  acute  or  chronic  form,  accord- 
ing as  it  is  or  is  not  attended  by  the  signs 
of  acute  inflammation. 

Acute  Granular  Conjunclivilis  {Papil- 
lary Trachoma ;  Chronic  Blcnnorrhaa). — 
This  is  rare  in  this  country  and  should 
be  difTerentiated  from  the  violent  ex- 
acerbations to  which  the  chronic  forms 
of  the  malady  are  liable.    In  this  variety 


there  are  all  the  signs  of  purulent  con- 
junctivitis, with  the  development  of  th€ 
granulations.  The  lids  swell  and  the 
conjunctiva,  both  bulbar  and  palpebral, 
becomes  injected.  The  papilla  are  en- 
larged, and  the  characteristic  granula- 
tions are  about  the  size  of  the  head  of  a 
pin,  and  are  situated,  for  the  most  part, 
in  the  retrotarsal  folds — chiefly  the  up- 
per. They  are  also  found  scattered 
throughout  the  conjunctival  membrane. 

At  first,  lacrymation  is  usually 
marked,  but,  later,  considerable  dis- 
charge appears,  and  superficial  ulcers 
form  at  the  limbus. 

After  several  weeks  the  disease  gradu- 
ally subsides,  usually  leaving  some  cica- 
trices in  the  lids  to  indicate  its  presence, 
although  in  other  cases,  after  the  ab- 
sorption of  the  granulations,  the  mucous 
membrane  may  be  quite  smooth. 

If  the  inflammation  be  but  slight  and 
not  sufficient  to  absorb  the  granulations, 
the  process  may  run  into  the  chronic 
form. 

Chronic  granular  conjunctivitis  is  usu- 
ally primary,  but  it  may  be  due  at  times 
to  the  imperfect  disappearance  of  the 
acute  granulations.  The  constant  factor 
in  this  variety  of  trachoma  is  the  tra- 
choma-follicle, as  it  exists  in  all  of  the 
different  degrees  in  which  these  condi- 
tions are  met  with. 

The  development  of  chronic  granular 
conjunctivitis  is  often  very  insidious. 
Usually,  at  first,  marked  lacrymation  is 
present,  although  there  is  but  little  secre- 
tion. If  the  cornea  has  become  vascular, 
photophobia  may  be  a  most  distressing 
symptom.  The  lids  are  swelled,  and, 
upon  their  eversion,  the  characteristic 
granulations  spring  into  view.  They  re- 
semble sago-like  prominences  arranged 
in  parallel  rows,  and  are  found  in  the 
superficial  layers  of  the  conjunctiva,  es- 
pecially in  the  fornix.     Rarely  a  few 


CONJUNCTIVA.     GRANULAR  CONJUNCTIVITIS.    COMPLICATIONS. 


293 


smaller  isolated  granules  will  be  seen  on 
the  bulbar  conjunctiva.  At  first  they 
are  found  in  the  lower  cul-de-sac,  but  the 
upper  cul-de-sac  is  soon  affected  and 
shows  the  greatest  development  of  the 
follicles. 

After  a  few  weeks  or  months  the  gran- 
ulations give  rise  to  a  more  or  less  active 
vascular  reaction,  attended  with  swell- 
ing of  the  papillae  and  a  muco-purulent 
discharge.  The  papillas  may  become  so 
large  that  they  may  obscure  the  granula- 
tions. Occasionally  the  granulations  be- 
come absorbed,  but  in  the  majority  of 
cases  fresh  eruptions  of  follicles  present 
themselves  during  the  period  of  regress- 
ive inflammation  and  go  through  the 
same  changes  as  their  predecessors. 

After  a  certain  duration,  grayish  lines 
of  fibrous  tissue  make  their  appearance, 
and  the  final  stage  of  cicatrization  be- 
gins. As  a  result  of  this,  dense  scar-tis- 
sue forms;  this  exerts  traction  upon  the 
tarsus — already  softened  by  the  pre-exist- 
ing disease — and  produces  the  deform- 
ities of  the  lids  so  characteristic  of  the 
affection. 

Complications. — The  corneal  compli- 
cation may  take  the  form  of  pannus  or 
of  ulceration. 

Pannus  consists  in  the  formation  of  a 
vascular  tissue  of  neoformation  on  the 
cornea,  which  begins  at  the  limbus  and 
invades  the  centre.  At  the  location  of 
the  pannus  the  surface  of  the  cornea  is 
uneven  and  roughened,  and  there  is  a 
superficial  gray  and  transparent  haze, 
which  is  infiltrated  by  numerous  vessels; 
these  originate  from  the  blood-vessels  of 
the  conjunctiva.  The  pannus  usually  be- 
gins in  the  upper  part  of  the  cornea  and 
frequently  stops  below,  in  a  sharp, 
straight,  horizontal  border-line.  Later, 
it  may  develop  at  other  parts  of  the 
limbus;  so  that  the  entire  cornea  may 
become  covered.     Vision  is  affected  as 


soon  as  the  pannus  reaches  the  pupil, 
which,  if  the  cornea  be  entirely  covered, 
may  be  reduced  to  light-perception. 

'WTien  ulceration  occurs,  it  is  either  at 
the  edge  of  the  pannus  or  upon  a  portion 
of  the  cornea  which  had  hitherto  been 
uninvolved.  It  usually  occasions  great 
photophobia  and  lacrymation. 

The  hypertrophy  of  the  conjunctiva 
increases  until  the  diseased  process  has 
run  its  course,  w^hen  it  begins  to  shrink, 
and  is  replaced  by  cicatricial  tissue,  with 
all  its  attendant  evil  consequences  to  the 
normal  contour  and  function  of  the  lids. 
The  degree  of  cicatrization  depends  upon 
the  severity  of  the  early  stages  of  the 
disease. 

The  beginning  of  the  scar-formation 
shows  itself  in  the  tarsal  conjunctiva, 
narrow,  whitish  lines  permeating  the  lat- 
ter. These  lines  become  more  numerous 
and  form  a  fine  net-work,  which  gradu- 
ally spreads;  the  conjunctiva  included 
within  the  meshes  becomes  attenuated, 
until  quite  smooth  and  white. 

The  hypertrophied  conjunctiva  in  the 
fornix  gradually  shrinks,  becoming 
shorter,  and  the  folds  of  the  conjunctiva 
in  that  location  disappear.  This  is 
known  as  symhlepharon  posterior.  In  ex- 
treme cases  the  cul-de-sacs  are  reduced 
to  shallow  fissures  between  the  lid  and 
the  globe.  The  lids  become  distorted, 
through  the  cicatricial  changes  in  the 
cornea  and  tarsus,  the  latter  participat- 
ing in  the  inflammation,  as  well  as  the 
conjunctiva.  It  becomes  much  hyper- 
trophied, especially  along  its  lower  mar- 
gin, where  the  conjunctival  vessels  per- 
forate it.  It  is  especially  in  this  position 
that  the  shrinking  of  the  conjunctiva, 
which  follows  later,  makes  itself  most 
felt,  and  is  the  main  factor  in  the  pro- 
duction of  the  bow-like  distortion  of  the 
lids,  produced  by  trachoma.  The  cilia 
no  longer  occupy  their  normal  position, 


294 


COXJUXCTIVA.    GKAXULAK  CONJUNCTIVITIS.     ETIOLOGY. 


but  become  displaced,  and  cause  great 
irritation  by  being  brought  in  contact 
with  the  cornea.  This  irritation  is 
further  augmented  if  the  shrinkage  of 
the  tarsus  continues,  cjnd  entropion  is 
produced. 

Ectropion,  of  the  lower  lid  especially, 
may  also  be  originated,  due  to  the  con- 
traction of  the  orbicularis  and  exerted 
upon  the  lids — already  prone  to  ever- 
sion  by  the  swelling  of  the  conjunctiva. 

Xerosis  of  the  conjunctiva  occurs  as  a 
result  of  the  cicatrices.  The  blood-sup- 
ply to  the  conjunctiva  is  shut  off  and  its 
epithelium  undergoes  fatty  degenera- 
tion. The  surface  of  the  membrane  then 
becomes  dry  and  smooth  and  almost 
leathery,  and  the  corneal  epithelium  also 
becomes  thicker  and  its  transparency 
much  interfered  with.  The  eye  finally 
becomes  blind  and  a  source  of  continued 
annoyance,  by  reason  of  the  constant 
sensation  of  local  drj-ness  experienced. 

The  pannus  may  clear  up  entirely, 
leaving  a  normal  cornea  beneath.  If 
there  be  ulceration,  however,  opacities 
remain,  which  disturb  vision  according 
to  the  extent  to  which  they  involve  the 
pupillary  area  of  the  cornea.  Fre- 
quently, as  a  result  of  pannus,  there 
occurs  a  connective-tissue  metamorpho- 
sis, which  greatly  interferes  with  the 
transparency  of  the  cornea.  Another  re- 
sult of  pannus  sometimes  is  a  bulging, 
or  staphylomatous,  condition  of  the  cor- 
nea, the  tissues  of  which  have  become 
so  altered  that  they  give  way  before  the 
normal  intra-ocular  tension. 

Etiolo^.  —  In  general,  the  disease 
may  be  said  to  arise  from  poor  hygienic 
conditions.  It  develops  in  institutions 
where  the  inmates  are  crowded  together, 
in  armies,  orphan-asylums,  almshouses, 
and  the  like.  It  is  probable  that  the  so- 
called  lymphatic  or  scrofulous  tempera- 
ment predispose  toward  it,  although  the 


disease    may    attack    those    in    perfect 
health. 

Trachoma  always  arises  through  in- 
fection from  another  eye  already  in- 
fected, by  means  of  the  secretion;  only 
under  exceptional  circumstances,  when 
the  air  is  heavily  charged  with  the 
poison,  can  it  be  the  medium  of  com- 
munication of  the  disease.  The  in- 
fectious nature  of  the  secretion  is  doubt- 
less due  to  micro-organisms;  but,  while 
numerous  bacteria  are  found  in  the  secre- 
tion, gonococci,  streptococci,  etc.,  the 
specific  germ  has  not  yet  been  isolated. 

Etiological  factor  in  acute  contagious 
conjunctivitis  a  small,  unknown  bacillus. 
Weeks  (N.  Y.  Eye  and  Ear  Infirmary 
Reports,  Jan.,  '95). 

It  is  always  contagious, — frequently 
epidemic.  The  symptoms,  which  vary 
in  severity,  begin  two  or  three  days  after 
infection,  with  gluing  together  of  the 
eyelids  on  awakening  in  the  morning,  and 
small,  yellowish  masses  at  the  base  of 
the  lashes.  There  is  increased  lacryma- 
tion,  congestion,  and  turbid  discharge. 
It  usually  begins  first  in  one  eye,  but 
affects  both  in  its  course.  There  are 
burning  pains  and  the  sense  of  a  foreign 
body;  the  lids  are  swelled  and  discol- 
ored; and  the  eyeball  is  of  a  rosy  tint, 
which  has  given  the  affection  the  name 
of  "pink-eye."  The  symptoms  continue 
to  increase  for  two  or  three  days,  and 
frequently  a  slight  coryza  arises.  Victor 
Morax  and  G.  W.  Beach  (Archives  of 
Ophth.,  vol.  XXV,  No.  1,  '97). 

Nine  thousand  one  hundred  and  sixty- 
si.x  cases  of  trachoma  (1500  of  which  were 
complicated  with  corneal  affections)  ex- 
amined to  discover  whether  there  is  any 
accountable  pathogenic  microbe  or  not. 
It  was  concluded  that  there  is  none,  but 
that  the  morbid  entity  of  trachoma  has 
an  histology  which  is  characteristic  and 
absolutely  different  from  that  of  follicu- 
lar conjunctivitis.  Lessening  the  alka- 
linity of  the  lacryma!  secretion  tends  to 
the  acquisition  of  conjunctival  diseases. 
V.  L.  Matkovic  (Rec.  d'Ophtal.,  Feb.,  '98). 

Trachoma  is  due  to  encapsulated  diplo- 
eoccus,   1  'A   to  2  millinif'trus   in   Iciiglli 


CONJUNCTIVA.     GRANULAR  CONJUNCTIVITIS.     TREATMENT. 


■Zd5 


and  5  niillimetres  in  breadth,  which  \s 
not  decolorized  by  the  Gram  method  of 
staining,  and  wliose  septum  at  times  has 
an  affinity  for  aniline  stains,  causing  the 
diplococcus  to  simulate  bacillus.  This 
organism  is  constantly  present  in  the 
trachoma-follicle  and  secretions,  before 
astringent  and  antiseptic  remedies  have 
been  employed.  E.  F.  Syndecker  (Jour. 
Med.  and  Surg.,  Apr.,  '99). 

A  thorough  inspection  of  36  public 
schools  in  New  York  in  July  of  last 
year  showed  that,  of  57,450  children  ex- 
amined, GG90  were  found  to  have  some 
form  of  contagious  eye  disease.  Of 
these,  2328  were  severe  trachoma,  3243 
were  mild  trachoma,  and  1099  acute 
purulent  conjunctivitis.  A  large  num- 
ber of  cases  were  excluded  from  the 
schools,  and  there  was  a  coincident  in- 
crease in  the  number  of  trachoma  cases 
treated  in  the  New  York  eye  hospitals. 
The  question  of  the  contagiousness  of 
trachoma  is  still  unsettled.  It  is  prob- 
able that  children  suffering  from  eye 
diseases  of  this  class  should  be  excluded 
from  the  schools  until  the  condition  has 
been  cured.  Lambert  (Med.  Record, 
Feb.  21,  1903). 

As  the  secretion  alone  causes  the  in- 
fection, therefore,  the  danger  of  in- 
fection depends  upon  the  strength  of 
the  secretion;  the  richer  this  is,  the 
greater  will  the  danger  be  to  surround- 
ing persons. 

The  transfer  of  secretion  from  one  eye 
to  another  is  usually  accomplished  by 
the  fingers  or  toilet  articles  which  are 
brought  into  contact  with  the  eyes,  as 
handkerchiefs,  towels,  sponges,  etc. 
This  is  more  apt  to  happen  when  num- 
bers are  crowded  together  and  are  likely 
to  use  these  articles  in  common. 

Pathology. — In  trachoma  we  see  an 
excessive  degree  of  development  of  the 
papilliE  of  the  mucous  membrane  and  the 
formation  of  the  granulations.  Jlicro- 
scopically,  the  granulations  may  have  an 
imperfect  capsule  or  may  have  no  cap- 
sule, but  they  seem  to  grow  from,  or  in, 


the  stroma  of  the  conjunctiva.  In  the 
acute  form  the  granulations  consist  of 
lymph-cells  alone.  They  are  to  be  re- 
garded as  new  growths  in  the  conjunc- 
tiva, and,  in  addition  to  the  lymphoid 
cells,  the  mass  of  cells  and  connective 
tissue  is  penetrated  by  blood-vessels. 
The  chronic  granulations  consist  of 
lymph-cells  toward  the  surface,  but  their 
bases  are  formed  chiefly  of  connective 
tissue.  Gradually  the  cellular  elements 
are  transformed  into  connective  tissue, 
and  in  this  way  cicatricial  degeneration 
of  the  conjunctiva  is  brought  about  at 
each  spot  where  a  granulation  was 
seated. 

The  development  of  the  papillae  is  not 
characteristic  of  trachoma,  for  it  is  pres- 
ent in  moderate  degree  in  every  lasting 
inflammation  of  the  conjunctiva,  as  in 
chronic  catarrh,  vernal  and  follicular 
catarrh,  and  purulent  conjunctivitis. 

Prognosis. — Acute  granular  conjunc- 
tivitis, or  trachoma,  is  characterized  by 
its  chronicity  and  by  the  serious  conse- 
quences to  vision;  this,  added  to  its  con- 
tagiousness, makes  it  one  of  the  most 
dreaded  of  eye  diseases.  Relapses  occur 
frequently  and  persistently  and  may 
occasion  all  of  the  intense  inflammatory 
symptoms  of  acute  granulations.  Its 
great  danger  lies  in  its  contagiousness 
and  the  great  rapidity  with  which  it 
spreads  through  schools  or  any  institu- 
tions where  large  numbers  of  inmates  are 
gathered  together,  by  the  careless  use  of 
towels  and  common  utensils.  The  prog- 
nosis is.  therefore,  always  grave,  and  de- 
mands the  adoption  of  great  precautions 
to  prevent  a  disastrous  epidemic. 

Treatment. — Prophylaxis  is  obviously 
of  the  greatest  importance,  and,  as  the 
conspicuously-dangerous  element  is  the 
secretion,  cleanliness,  adequate  air-space, 
and  proper  ventilation  of  the  sleeping- 
rooms   must   be    insisted    upon    in    all 


296 


COXJUXCTIVA.    GRANULAR  CONJUNCTIVITIS.     TREATMENT. 


crowded  institutions.  Every  patient 
should  be  provided  with  liis  own  basin 
and  towel,  or,  better  still,  should  be  re- 
quired to  wash  under  "running  water." 
When  the  disease  is  once  established, 
rigorous  isolation  of  all  those  afflicted 
should  be  practiced. 

The  chief  aim  of  the  treatment  must 
be  to  check  the  development  of  the  hy- 
pertrophy of  the  conjunctiva,  and  bring 
about  absorption  of  the  granulations  in 
order  to  prevent  the  destruction  of  the 
mucous  membrane,  and  to  reduce  the  pre- 
vious results  of  the  disease  to  a  mini- 
mum. 

In  the  early  stages,  frequent  washings 
of  the  conjunctiva  with  a  10-grain  solu- 
tion of  boric  acid  and  bichloride  solu- 
tions should  be  employed;  especially  is 
this  true  of  acute  granulations.  If  there 
be  much  pain  and  photophobia  and  some 
haze  of  the  cornea,  atropine  should  be 
instilled  in  conjunction  with  the  cleans- 
ing lotions.  A  nitrate-of-silver  solution 
should  be  employed  so  soon  as  the  dis- 
charge becomes  marked,  in  the  same 
manner  and  to  meet  the  same  indications 
as  already  described  in  the  treatment  of 
other  forms  of  conjunctivitis. 

Perfect  rest  indicated  for  trachomatous 
eyes.  Instillations  of  atropine,  together 
with  use  of  bandages  or  cataract  shields 
during  the  day,  are  of  value.  Before 
bandaging  a  weak  iodoform  ointment 
may  be  applied  to  conjunctivte  and  lids. 
At  night  the  protection  should  be  re- 
moved and  the  patient  kept  in  the  dark. 
Properly-fitting  glasses  sliould  be  used 
when  the  eyes  are  not  at  rest.  Massage 
practiced  every  week  or  so  by  rubbing 
the  granulations  lightly  with  a  strabis- 
mus-hook. N.  B.  Jenkins  (N.  Y.  Med. 
Jour.,  May  19,  1900). 

The  treatment  of  chronic  granular 
conjunctivitis  in  the  early  stages  must 
be  non-irritating;  but,  so  soon  as  the 
discharge  becomes  marked,  silver  nitrate 
becomes  the  sovereign  remedy.     When 


the  acute  stage  has  moderated  and  the 
discharge  is  less  marked,  the  silver  salt 
should  be  replaced  by  other  caustics: 
copper,  alum,  zinc,  etc.  These  drugs 
must  be  continued  months  and  perhaps 
even  years,  until  every  trace  of  hyper- 
trophy has  gone  and  the  conjunctiva  has 
become  perfectly  smooth  and  clean. 

The  nitrate-of-silver  solution  should 
be  applied  but  once  daily,  and  at  times 
when  there  are  marked  signs  of  irrita- 
tion, must  be  wholly  withdrawn  for  a  few 
days,  while  these  are  combated  with  atro- 
pine and  milder  antiseptics. 

The  prognosis  is  quite  favorable.  It 
should  be  treated  by  applications  of  ni- 
trate of  silver  of  the  strength  of  1  to  40 
or  1  to  50,  weaker  solutions  being  less 
effective.  The  bacilli  found  were  de- 
void of  movement.  Inoculation  of  a  cult- 
ure on  the  human  conjunctiva  produced 
a  typical  attack.  Victor  Morax  and  G. 
W.  Beach  (Arch,  of  Ophthal.,  vol.  xxv, 
No.  1). 

As  it  is  necessary  that  the  local  treat- 
ment shall  be  continued  for  such  a  long 
time  during  the  stage  of  cicatrization,  to 
prevent  relapses,  an  ointment  of  1  grain 
of  tannin  to  1  drachm  of  vaselin  may  be 
ordered  and  may  be  applied  by  the  pa- 
tient himself.  Copper  may  be  applied 
in  the  same  strength. 

After  an  experience  with  3000  cases  of 
trachoma  the  medicinal  management  of 
trachoma  is  advocated,  surgery  being  re- 
served for  those  cases  (probably  40  per 
cent.)  rebellious  to  medicines.  II.  Kuhnt 
(Klin.  Monats.  f.  Augcnh.,  Mar.,  '98). 

In  trachoma  iodine  dissolved  in  a 
petroleum  preparation,  as  recommended 
by  NesnamofT,  is  of  value.  Slight  cases 
of  granular  lids  may  be  cured  in  two  or 
three  weeks,  while  severe  cases  may  re- 
quire as  many  months,  but  the  pannua 
begins  to  improve  markedly  in  the  first 
week  or  two.  For  mild  cases  the  1-per- 
cent, solution  is  applied  every  other  day; 
in  more  severe  cases  a  2-per-cent.  solu- 
licin.  IT.  11.  Seabrook  (N.  Y.  Kye  and 
E;ir  Tiifiimary  Reports,  Jan.,  1900). 


CONJUNCTIVA.    GRANULAR  CONJUNCTIVITIS.    TREATMENT. 


297 


Tlie  writer  poiiitdl  out  some  years 
ago  that  the  essentials  of  any  treatment 
likely  to  prove  effective  were  fairly  well 
afforded  by  ichthyol.  These  essentials 
he  laid  down  thus:  The  application 
must  constrict  the  dilated  vessels,  re- 
move the  infiltration  and  thickening  of 
the  conjunctiva,  and  alleviate  the  vari- 
ous subjective  symptoms,  particularly 
the  pain,  the  lacrymation,  and  the  pho- 
tophobia. He  found  that  ichthyolate  of 
ammonia,  in  50-per-cent.  solution,  met 
these  requirements  better  than  any 
other  application  he  had  yet  employed. 
Jacovides  also,  and  Darier,  have  spoken 
highly  of  ichthyol  in  trachoma.  The 
latter  used  it  undiluted;  but  this  does 
not  seem  to  be  a  wise  example  to  fol- 
low. The  former  employed  the  drug  in 
a  great  number  of  different  affections  of 
conjunctiva  and  cornea,  and  found  that 
its  action  on  the  pannus  of  trachoma 
was  specially  marked  and  beneficial. 
Denti,  too,  used  ichthyol  in  trachoma. 
In  his  experience  the  aeuter  forms  were 
much  more  favorably  influenced  by  it 
than  the  more  chronic;  its  action  was 
specially  valuable  in  cases  showing  su- 
perficial ulceration  along  with  pannus. 
Bialetti  speaks  strongly  in  favor  of  a 
lotion  of  ichthyol  (50  per  cent.)  painted 
on  the  everted  upper  lid  and  then 
washed  off  with  distilled  water.  The 
first  effect  of  application  is  a  slight 
burning  sensation,  which  quickly  passes 
off,  and  is  succeeded  by  relief  from  pho- 
tophobia, blepharospasm,  and  pain,  and 
this  relief  is  not  merely  transitory. 
The  vessels  of  the  pannus  shrivel  up 
under  its  use,  and  the  corneal  opacity 
clcai-3.  Eberson  (Clin.  Ocul.,  Palermo, 
June,  1901 ;  Edinburgh  Jled.  Jour.,  June. 
1002). 

Copper  citrate  does  not  cure  tra- 
choma more  quickly  than  other  non- 
operative  methods.  It  produces  ab- 
sorption and  disappearance  of  granula- 
tions and  hyportrophied  papilUis  quiti> 
as  rapidly  as  other  applications.  It 
produces  less  irritation  in  the  lids;  less 
pain  and  discomfort  to  the  patient. 
Important,  and  a  corollary  to  its  al- 
most painlessness,  patients  will  use  it 
regularly  in  homo  treatment.  The 
remedy   is  host  applied   in   the  form  of 


a  5-per-cent.  to  10-per-cent.  ointment  of 

which     white     vaselin     ia     the     base. 

Wright  (Jour.  Amer.  Med.  Assoc.,  Aug. 

8,  1903). 

Numerous     surgical  procedures  have 

been  proposed  for  the  excision  of  the 

granulations,  and  some  observers  advise 

the  excision  of  the  entire  fornix  of  the 

conjunctiva.     It  is  probable,  however, 

that  the  resultant  cicatrices  cause  more 

mischief  than  those  which  would  result 

if  the  disease  were  allowed  to  take  its 

course.     This   form   of  treatment  has, 

therefore,  met  with  but  little  favor  from 

the  more  conservative  clinicians. 

A  less  harmful  method,  and  one  which 
is  frequently  employed  by  the  ophthal- 
mologists of  this  country  at  least,  con- 
sists in  the  expression  of  the  granula- 
tions by  means  of  forceps.  Knapp  has 
devised  a  roller-forceps  especially  for  this 
purpose.  The  reaction  following  this 
procedure  is  at  times  quite  severe;  so 
that  it  is  advisable  to  employ  ice-com- 
presses for  some  time  afterward;  to  pre- 
vent a  recurrence  of  the  granulations  it 
is  always  well  to  follow  the  expression 
by  applications  of  silver  nitrate. 

The  amount  of  benefit  obtained  from 
the  expression  method  is,  in  general,  pro- 
portioned to  the  quantity  of  exudate  in 
and  beneath  the  conjunctiva;  where 
there  had  been  a  considerable  amount 
of  exudation,  the  cure  is  immediate  and 
apparently  permanent.  Jackson  (Med. 
and  Surg.  Reporter,  Aug.  20,  '92). 

[a)  In  the  first  stage  of  trachoma  the 
most  efficient  mode  of  surgical  interfer- 
ence is  that  of  expression,  combined  with 
superficial  scarification  and  the  introduc- 
tion of  a  germicide  by  the  use  of  a  brush. 
(6)  In  the  second  stage,  where  surgical 
interference  is  advisable,  the  treatment 
known  as  "grattage"  should  be  combined 
with  expression  in  some  cases.  Can- 
thotomy  or  canthoplasty,  if  necessary, 
gives  the  most  satisfactory  results,  (e) 
The  operations,  as  above  advised,  con- 
vert a  contagious  into  a  non-contagious 
condition,  and  the  patient  may  be  ad- 


298 


COXJU>"CTIVA.     GKAXULAR  C0^■JU^XTIVIT1S.     TREATMENT. 


mitted  to  wards  for  ordinaiy  surgical 
cases  without  fear  of  infection.  Weeks 
(Jour.  Amer.  Med.  Assoc,  Sept.  3,  '92). 

The  procedure  of  Darier  and  Abadie 
used  in  seventir-five  cases;  but  one  grave 
complication  resulting  from  its  use  wit- 
nessed: a  case  of  total  symblepharon 
due  to  neglect  in  the  dressing.  If  a 
radical  cure  of  the  disease  could  be  ob- 
tained by  this  method  of  treatment,  the 
pain  and  great  local  reaction  following 
the  operation  might  be  atoned  for,  but 
a  single  instance  of  permanent  cure  was 
never  seen.  Trousseau  (Archives  d'Oph- 
tal.,  Apr.,  '93). 

Conclusion  from  the  results  obtained 
by  the  treatment  of  two  hundred  cases: 
Rapid,  perfect,  and  permanent  recovery 
by  expression  alone,  or  expression  fol- 
lowed by  mild  caustic  treatment,  takes 
place  in  the  majority  of  cases,  especially 
of  the  purely  follicular  type.  Imperfect 
recovery — i.e.,  disappearance  of  tra- 
choma, leaving  more  or  less  shrinkage  of 
the  conjunctiva — results,  as  a  rule,  in 
old  neglected  cases  of  inflammatory  tra- 
choma. Relapses  that  are  cured  by  a 
second  or  third  operation  occur  in  both 
the  simple  and  inflammatory  forms.  The 
operation  itself  has  never  injured  an  eye. 
Knapp  (Archives  of  Ophthal.,  Jan.,  '93). 

Study  of  101  cases  of  trachoma;  ex- 
pression-treatment as  practiced  with 
Knapp's  roller-forceps  favored.  U.  Hell- 
gren  (Mittheil.  a.  d.  Augen.  d.  Carolin. 
mcd.-chir.   Inst.,   Stockholm,   '98). 

The  greatest  emphasis  must  be  laid 
upon  tlie  necessity  of  placing  the  sub- 
jects under  the  best  hygienic  conditions. 
In  the  ease  of  patients  confined  to  hos- 
pitals, asylums,  etc.,  the  utmost  pains 
should  be  taken  to  secure  good  ventila- 
tion, nourishing  food,  and  perfect  clean- 
liness, personal  as  well  as  general. 

When  pannus  has  occurred  and  the 
thickening  of  the  conjunctiva  subsides, 
the  corneal  disease  will  usually  abate 
pari  passu;  so  that  the  treatment  of 
pannus  and  of  ulcers  of  the  cornea  re- 
solves itself  into  that  of  the  conjunctiva. 


Atropine  should  be  instilled  to  combat 
any  existing  iritis. 

If  the  pannus  is  unusually  dense  and 
is  partly  made  up  of  connective  tissue, 
further  absorption  may  be  obtained  by 
exciting  a  violent  inflammation  of  the 
conjunctiva.  An  infusion  of  jequirity  is 
frequently  employed  for  this  purpose. 
This  is  prepared  by  steeping  the  ground 
jequirity-bean  for  twenty-four  hours  in 
cold  water.  With  this  infusion,  the  con- 
junctiva of  the  everted  lids  is  painted 
thoroughly  two  or  three  times  daily.  A 
croupo-purulent  conjunctivitis  is  excited 
and  is  combated  in  the  same  manner  as 
already  described  under  this  disease. 
When  the  inflammation  has  run  its 
course,  the  cornea  is  frequently  found  to 
have  regained,  in  a  measure,  its  former 
transparency. 

Jequirity  beneficial  in  those  eases  of 
granular   conjunctivitis   where   there   is 
superficial    vascularity    of    the    cornea. 
Also  used  the  drug  with  advantage  in 
the  fibrous  condition  which  often  follows. 
Emerson  (N.  Y.  Med.  Jour.,  Feb.  11, '93). 
Pannus  successfully  treated  with  anti- 
pyrjne.    As  the  insufflations  are  painful, 
cocaine  should  be  used  at  first,  and  ap- 
plication made  daily  or  every  third  day, 
according  to  the  gravity  of  the  case  and 
the  efi'eet  desired.     The  violent  reaction 
that  follows   should   be  treated  by  fre- 
quently-changed,   hot,    antiseptic    com- 
presses.    This  method  is  not  applicable 
to    symptomatic    pannus,    in  which    the 
primary  condition  should  be  first  reme- 
died.    Vigncs    (Rccueil   d'Ophtal.,  Aug., 
'92). 
The    operations   of   peritomy,    which 
consists  in  the  destruction  of  the  vessels 
supplying   the   pannus,    has    also    been 
much  vaunted  for  the  cure  of  this  condi- 
tion.   After  a  ring  of  conjunctival  tissue 
about  five  millimetres  from  the  margin 
of  the  cornea  is  excised  by  scissors,  the 
underlying  connective  tissue  is  dissected 
off  the  sclera,  which  is  then  laid  bare. 
Xerosis  admits  of  palliation  only  by 


CONJUNCTIVA.    PHLYCTENULAR  CONJUNCTIVITIS.    SYMPTOMS. 


299 


emollients — such  as  glycerin,  olive-oil,  or 
vaselin — applied  freely  several  times 
daily. 

The  distortion  of  the  lids,  with  the 
resultant  trichiasis  and  entropion  and 
ectropion  which  it  occasions,  only  yields 
to  operative  measures. 

Phlyctenular  Conjunctivitis  (Lym- 
phatic, or  Strumous,  Conjunctivitis). 

Definition. — Phlyctenular  conjunctivi- 
tis is  a  frequent  form  of  inflammation 
of  the  conjunctiva  characterized  by  the 
eruption  of  one  or  more  grayish  eleva- 
tions or  phlyctenuliE  on  the  bulbar  con- 
junctiva. It  usually  occurs  in  scrofulous 
children  under  ten  years  of  age. 

Symptoms. — Children  suffering  from 
this  disease  have  the  characteristic  stru- 
mous appearance.  They  are  either  pale 
and  thin  or  bloated  and  flabby.  The 
cervical  lymphatics  are  enlarged  and  the 
nose  and  upper  lip  tumefied.  There  is 
a  moist,  eczematous  eruption  on  the  face 
and  constant  watering  of  the  eyes  and 
nose.  Otorrhcea  is  frequent.  A  dis- 
tressing symptom — intense  fear  of  light 
and  blepharospasm,  due  to  the  corneal 
involvement,  which  occurs  in  most  cases 
of  phlyctenular  conjunctivitis  —  com- 
pletes a  clinical  picture  which  renders 
an  examination  of  the  eyes  almost  su- 
perfluous. 

An  inspection  of  the  eye,  however, 
will  reveal  the  presence  of  phlyctenule. 
These  appear  as  minute  red  eminences, 
either  alone  or  in  numbers.  In  the  lat- 
ter case  they  are  situated  on  the  limbus 
of  the  conjunctiva  and  resemble  grains 
of  fine  sand. 

In  the  simple,  or  solitary,  variety  the 
injection  of  the  blood-vessels  is  localized 
immediately  around  each  phlyctenule; 
but  in  the  multiple,  or  miliary,  variety 
the  conjunctival  injection  is  general  and 
is  usually  quite  marked.  In  the  latter 
variety  there  is  also  much  photophobia 


and  lacrymation  and  rarely  some  dis- 
charge. Usually  there  is  an  eruption 
of  these  phlyctenule  on  the  cornea  as 
well.  This  is  always  accompanied  by  an 
increase  in  the  photophobia  and  lacrj-- 
mation  and  adds  greatly  to  the  gravity 
of  the  disease. 

Etiology. — Phlyctenular  conjunctivi- 
tis occurs  chiefly  among  the  poorer 
classes,  and  is  fostered  by  the  improper 
and  insufficient  nourishment  which  they 
receive  and  by  their  damp  and  unhy- 
gienic surroundings.  It  may  be  found, 
however,  in  children,  otherwise  healthy, 
whose  vitality  has  been  depressed  by 
febrile  disturbances,  such  as  measles, 
whooping-cough,  scarlet  fever,  and  the 
like.  The  disease  rarely  occurs  in  adults, 
and  only  when  a  tendency  toward  this 
disease  was  manifested  in  youth. 

Emphasis  upon  the  relationship  exist- 
ing between  phlyctenular  diseases  of  the 
cornea  and  conjunctivitis  and  general 
malnutrition.  Wallace  (University  Med. 
Mag.,  Apr.,  •92). 

Scrofula  is  the  causative  factor  in  95 
per  cent,  of  all  plilyctenular  diseases  of 
the  conjunctiva.  Baas  (Woch.  f.  Therap. 
u.  Hyg.  d.  Auges.,  Sept.  29,  '98). 

Strumous  diathesis  present  in  90  per 
cent,  of  200  cases  of  phlyctenular  con- 
junctivitis. It  is  a  most  important  and 
perhaps  a  necessary  factor.  Phlyctenules 
are,  however,  not  a  local  tuberculous 
process,  since  animals  cannot  be  inocu- 
lated with  tubercle  for  them.  Axenfeld 
("Bericht  iiber  die  xxvi  Vcrsammhing 
der  Ophthal.  Gesellschs.  zu  Heidelberg"; 
Med.  and  Surg.  Reviews  of  Reviews,  Dec, 

•ns). 
Pathology.  —  A  phlyctenule  consists 
of  an  accumulation  of  l3Tnphoid  cells 
packed  closely  together  around  a  nerve- 
filament,  just  beneath  the  epithelium  of 
the  conjunctiva  or  cornea.  Soon  after 
its  formation  the  apex  of  the  mass  be- 
gins to  undergo  softening  and  liquefac- 
tion. The  epithelial  covering  is  thrown 
off  and  a  shallow  ulcer  remains.     The 


300 


COXJUXCTIVA.    CROUPOUS  CONJUNCTIVITIS. 


softening  process  continues,  the  epithe- 
liiun  dips  down  into  the  ulcer,  and  heal- 
ing occurs  in  ten  to  fourteen  days. 

After  a  time,  however,  a  fresh  out- 
break of  these  small  grayish  nodules 
occurs;  so  that  the  disease  may  extend 
over  months  and  at  times  years,  until  the 
age  of  puberty  is  attained,  when  the  eye 
seems  to  become  protected  against  fur- 
ther attacks. 

In  consequence  of  the  corneal  involve- 
ment, which  is  usually  associated  with 
phlyctenular  conjunctivitis,  there  is  al- 
ways a  greater  or  less  degree  of  cloudi- 
ness of  that  membrane;  so  that  vision  is 
interfered  with  and  the  patient  rendered 
incapable  of  fine  work.  The  scars  left 
upon  the  cornea  are  often  unsightly. 

Treatment. — This  must  be  directed,  in 
the  first  place,  toward  the  improvement 
of  the  general  condition.  Notwithstand- 
ing the  photophobia,  open-air  exercise 
should  be  positively  enjoined,  as  it  is 
absolutely  essential  for  the  well-being  of 
the  child.  All  bandages  should  be  re- 
moved, the  eyes  being  protected  by 
tinted  glasses  or  a  generous  shade.  The 
skin  should  be  rendered  more  active  by 
cold  or  salt  baths,  followed  by  brisk 
rubbing.  The  nourishment  should  be 
strengthening  and  administered  at  regu- 
lar intervals.  No  feeding  should  be  per- 
mitted between  meals;  all  sweets  and 
pastry  should  be  prohibited,  while  milk, 
fresh  eggs,  red  meat  (once  daily),  and 
proper  fruits  should  represent  the  bulk 
of  the  diet  recommended. 

Internally,  calomel  is  of  value  to  im- 
prove the  state  of  the  mucous  membrane 
of  the  alimentary  tract;  codliver-oil, 
syrup  of  the  iodide  of  iron,  syrup  of  the 
phosphate  of  lime,  and  arsenic  may  also 
be  administered  with  advantage. 

If  seen  in  the  early  Btageo,  it  is  ad- 
visable to  avoid  all  external  irritants  by 


the  use  of  smoked  glasses.  Gorecki  (Le 
Praticien,  May  20,  '90). 

Locally,  any  existing  blepharitis  or 
eczematous  eruption  about  the  eye 
should  be  combated  with  white-precipi- 
tate ointment  (1  to  2  per  cent.)  and  with 
silver  nitrate,  after  the  removal  of  all 
crusts  with  a  simple  soda  solution. 

In  the  simple  form,  where  there  is 
but  little  irritation,  calomel  should  be 
dusted  into  the  eye  once  daily.  This 
drug  combines  with  the  tears,  and  forms 
a  weak  solution  of  bichloride  of  mercury, 
which  exerts  a  most  beneficial  action 
upon  the  conjunctiva.  Care,  however, 
must  be  observed  that  iodine  is  not  being 
administered  internally  at  the  same  time 
with  the  calomel,  for  the  latter  in  this 
event  forms  with  the  iodine  an  iodide  of 
mercury  which  is  very  irritating  to  the 
eye. 

A  salve  of  the  yellow  oxide  of  mer- 
cury may  be  substituted  for  the  calomel 
in  many  cases  with  great  advantage. 

In  the  miliary  variety,  or  when  there 
is  recent  corneal  involvement  with  signs 
of  active  irritation,  these  drugs,  which 
are  irritating,  should  not  be  applied. 
In  these  cases  the  eyes  should  be  kept 
clean  with  frequent  washings  with  boric 
acid,  and  atropine  should  be  instilled  at 
regular  intervals. 

The  photophobia  and  blepharospasm 
usually  subside  with  the  improvement  in 
the  conjunctival  condition.  Should  it 
be  very  distressing,  however,  much  relief 
may  be  had  by  cold  baths  or  from  im- 
mersions of  the  child's  head  in  a  basin 
of  cold  water. 

Croupous  Conjunctivitis. 

Definition.  —  Croupous  conjunctivitis 
is  a  catarrhal  inflammation  of  tlie  con- 
junctiva in  which,  owing  to  the  intensity 
of  the  inflammation,  there  is  formation 
of  a  plastic  exudate  upon  the  conjunc- 
tival surfaces. 


CONJUN'CTIVA.    CROUPOUS  CONJUNCTIVITIS.    SYMPTOMS. 


301 


Symptoms. — It  usually  begins  with  the 
symptoms  of  an  acute  catarrh,  but  soon 
attains  a  severity  not  witnessed  in  ordi- 
nary catarrh.  The  lids  become  oedema- 
tous,  the  conjunctiva  much  reddened  and 
swelled,  especially  in  the  forni.x,  and  a 
discharge,  at  first  sero-purulent  but  later 
muco-purulent,  appears.  The  tarsal  mu- 
cous membrane  and  retrotarsal  folds  be- 
come covered  with  a  grayish-white  mem- 
brane, the  bulbar  conjunctiva  being  but 
rarely  involved.  The  pseudomembrane 
can  be  stripped  off,  disclosing  a  raw  and 
perhaps  bleeding  mucous  surface  be- 
neath, which  serves  to  distinguish  it 
from  the  diphtheritic  variety. 

The  pseudomembrane  usually  disap- 
pears after  two  weeks;  the  conjunctiva 
and  lids  reassume  their  normal  appear- 
ance and  the  signs  of  an  ordinary  ca- 
tarrhal conjunctivitis  reappear.  There 
are  no  resultant  cicatrices  and  vision  is 
but  seldom  affected,  the  cornea  being 
only  involved  when  the  false  membrane 
spreads  to  the  bulbar  conjunctiva,  which 
is  of  rare  occurrence. 

Diagnosis. — The  main  affections  from 
which  croupous  conjunctivitis  are  to  be 
differentiated  are  diphtheritic  conjunc- 
tivitis and  ophthalmia  neonatorum. 

Diphtheritic  Conjunctivitis. — In- 
stead of  being  limited  to  the  surface  of 
the  conjunctiva,  the  membrane  in  diph- 
theritic conjunctivitis  involves  its  deeper 
layers.  The  lids  are  hard  and  the  bulbar 
conjunctiva  is  involved,  and  there  is  fre- 
quent corneal  ulceration. 

The  diagnosis  of  diphtheritic  conjunc- 
tivitis must  rest  upon  the  presence  of 
pure  diphtheria  bacilli.  There  are  whit- 
ish conjunctival  patches  containing  dusky 
hffniorrhnges,  enlargement  of  pre-auricu- 
lar  glands,  coincident  diphtheria  of  the 
fauces,  and  subsequent  loss  of  knee-jerks, 
or  the  occurrence  of  paresis  or  paralysis. 
S.  Steplienson  (l^rit.  >red.  Jour.,  June  IS, 
•98). 


Fatal  case  of  diplitlieria  of  the  con- 
junctiva in  an  infant  11  months  old 
wliieh  was  wasted  and  had  evidently 
been  neglected.  A  bacteriological  ex- 
amination showed  the  Klebs-Loefller 
bacillus.  Diphtheria  of  the  conjunctiva 
is  far  from  rare  in  London.  Of  3412 
eye  patients  seen  at  two  hospitals  for 
children  there  were  43  instances  of  the 
disease.  Nearly  two-thirds  of  the  cases 
were  met  with  in  children  under  3  years 
of  age.  The  cases  were  most  frequent 
during  the  period  when  ordinary  diph- 
theria was  rife.  Three  only  of  the  en- 
tire number  belong  to  the  severe  types 
of  the  disease.  A  significant  fact  in  the 
case  described  is  that  the  patient  died 
from  a  toxajmia  due  to  conjunctival 
diphtheria  alone,  as  no  membrane  could 
be  found  in  the  nose,  mouth,  or  fauces, 
ilost  of  the  fatal  cases  so  far  reported 
have  had  involvement  of  the  nose, 
throat,  and  eyes.  S.  Stephenson  (The 
Ophthalmoscope,  Aug.,  1904). 
Ophthalmia  NEONATORUii. — In  this 
disease,  purulent  conjunctivitis,  the  dis- 
charge is  much  more  copious  and  puru- 
lent. Pseudomembranous  conjunctivitis 
is  never  found  among  the  newborn. 

Pathology. — The  local  inflammation 
must  be  regarded  as  a  severe  form  of 
catarrh  only,  in  which,  owing  to  the  in- 
tensity of  the  inflammatory  process,  the 
secretion  is  richer  in  fibrin  and  more 
prone  to  coagulation.  Various  grades  of 
this  plastic  quality  appear.  In  light 
cases  it  may  manifest  itself  as  a  simple 
condensation  of  the  secretion,  flakes  of 
fibrin  forming,  which  can  be  readily 
washed  off  of  the  conjunctiva.  In  some 
cases,  however,  the  exudate  has  the 
tenacity  of  a  true  diphtheritic  mem- 
brane. 

Case  of  chronic  membranous  conjunc- 
tivitis. A  boy,  8  years  old,  had  been 
under  obser\'ation  for  eighteen  months, 
with  a  thick,  firmly-attached,  yellowish- 
white  membrane  covering  the  conjunc- 
tiva of  the  upper  lid.  Treatment  had 
exerted  but  little  influence  upon  the 
membrane,  although  it  was  then  becom- 


302 


COXJOsXTIVA.    CROUPOUS  COXJUXCTIVITIS.     TEEATilEXT. 


ing  thinner.  The  eyeball  had  not  been 
seriously  damaged.  But  at  one  time  in 
its  course  there  had  been  a  severe  ex- 
acerbation of  the  disease  in  the  eye,  with 
soreness  of  the  tnroat  and  patches  of 
similar  membrane  on  the  tonsils,  and  rise 
of  temperature.  Two  children  that  he 
came  in  contact  with  in  the  same  ward 
at  this  time  developed  diphtheria  and 
died.  A  sister  of  this  boy  had  presented 
a  similar  chronic  membranous  conjunc- 
tivitis. After  it  had  lasted  nearly  a  year 
and  a  half  she  developed  scarlatina  with 
diphtheritic  patches  in  the  throat.    This 


Pathology  of  chronic  membranous  conjuncti- 
vitis.    {Boice.) 

was  accompanied  by  aggravation  of  the 
eye-symptoms,  and  necrosis  of  the  cornea, 
with  loss  of  useful  vision  in  both  eyes. 

Although  both  these  cases  were  care- 
fully studied  bacteriologically,  and  many 
micro-organisms  discovered,  the  Klebs- 
LoefHer  bacillus  was  present  in  each  case 
only  during  the  e.xaeerbation,  and  not 
at  any  other  time.  (See  illustration.) 
Lucien  Howe  (Trans.  Amer.  Ophth.  Soc, 
'97). 

In  making  a  positive  diagnosis  of 
diphtheritic  conjunctivitis  the  microscope 
does  not  aid  very  much.  The  xerosis 
bacillus  gives  exactly  the  same  reaction 
to  the  stain  that  the  Klebs-Loeffler 
bacillus  does;  it  looks  the  same  under 
the  microscope,  and  without  clinical 
symptoms  is  of  no  significance  wliatevcr. 
The  one  fact  which  settles  the  diagnosis 


is  the  inoculation  of  rabbits  or  guinea- 
pigs,  because  there  is  no  reaction  to  the 
xerosis  bacillus  and  there  is  to  the 
diphtheria  bacillus.  Pinckard  (Ophthal- 
mic Record,  Aug.,  '99). 

Ophthalmia  from  infection  with  the 
diphtheria  bacillus  is  not  rare  in  London. 
At  the  Xortheastem  Hospital  for  Chil- 
dren about  2  per  cent,  of  all  cases  are 
of  this  nature.  Stephenson  (Lancet,  Feb. 
17,  1900). 

Etiology. — Croupous  conjunctivitis  is 
a  disease  of  childhood,  and  usually  de- 
velops at  first  dentition.  Its  causal  fac- 
tors are  the  same  as  those  of  catarrh, 
but  certain  pyrexias,  particularly  measles 
and  pseudomembranous  vulvitis,  pre- 
dispose to  it.  It  may  be  associated  with 
croup  of  the  larynx,  trachea,  and  bron- 
chial tubes. 

Treatment. — Hot-water  compresses 
should  be  applied  night  and  day  until 
the  pseudomembrane  is  removed.  The 
general  health  should  be  seen  to,  and 
purgatives  administered  to  produce 
watery  evacuations.  All  caustics  and 
irritants  should  be  avoided  so  long  as 
the  pseudomembrane  is  present,  but  the 
eye  should  frequently  be  washed  with 
bichloride-of-mercury  (1  to  5000),  boric- 
acid,  chlorate-of-potash,  or  chloride-of- 
sodium  lotions.  As  soon  as  the  stage  of 
acute  catarrh  sets  in,  the  treatment 
should  be  the  same  as  in  acute  conjunc- 
tivitis. 

Instances  of  croupous  conjunctivitis 
that  was  complicated  by  disease  of  the 
entire  cornea,  an  abscess  involving  the 
lower  half  of  this  latter  membrane.  The 
usual  treatment  failing  to  arrest  the 
progress  of  the  disease,  a  dressing  of 
aristol  was  applied.  Tliis  was  followed 
in  a  short  time  by  the  most  favorable 
results.  Eliasberg  (Archives  d'Ophtal., 
Feb.,  '93). 

Irritating  remedies,  especially  silver  ni- 
trate, liariiiful  in  pseudomembranous  con- 
junctivitis. Valude  (Archives  d'Ophtal., 
Oct.,  '94). 


CONJUNCTIVA.     DIPHTHERITIC  CONJUNCTIVITIS.    TREATMENT. 


303 


Case  of  pseudomembranous  conjuncti- 
vitis in  newborn  child,  due  to  strepto- 
coccus, treated  by  Rou.k's  serum;  total 
loss    of    both    corna?.      Darier    (Annales 

d'Oculislique,  June,  'Do). 

Diphtheritic  Conjunctivitis. 

Definition.  —  Diphtheritic  conjuncti- 
vitis is  an  infrequent  specific  inflamma- 
tion of  the  conjunctiva,  attended  by  the 
formation  of  a  plastic  exudate  within  the 
layers  of  the  bulbar  and  tarsal  mem- 
brane. 

Symptoms. — The  exudation  penetrates 
deeply  into  the  tissue  and  causes  its 
death,  thereby  destroying  the  nutrition 
of  the  cornea  and  causing  subsequent 
loss  of  that  membrane.  The  lids  become 
hard,  board-like,  and  tumefied.  At  first 
there  is  a  scanty  sero-purulent  or  sanious 
discharge,  which  is  followed  by  a  more 
purulent  one  as  the  disease  progresses. 
The  secretion  is  very  contagious,  and,  if 
there  be  abrasions  at  the  orifices  of  the 
mouth  and  nose,  the  membrane  will 
quickly  invade  them.  Patches  of  mem- 
brane are  often  found  in  the  pharynx 
and  nares. 

After  the  period  of  infiltration — which 
lasts  from  one  to  two  weeks — has  sub- 
sided, the  membrane  is  thrown  off,  leav- 
ing a  raw,  granulated  surface.  At  times 
the  membrane  may  be  absorbed.  After 
a  time  vascularization  sets  in  and  the 
symptoms  of  an  ordinary  purulent  con- 
junctivitis supervene.  The  termination 
of  the  process,  however,  is  less  favorable 
than  in  the  catarrhal  form,  for  during 
the  period  of  cicatrization  changes  occur 
which  cause  atrophy  and  shrinking  of  the 
conjunctiva,  and  not  infrequently  occa- 
sions great  deformation  of  the  lids. 

Complications. — The  chief  complica- 
tion is  corneal  involvement,  which  oc- 
curs in  the  vast  majority  of  the  cases, 
and  occasions  the  intense  pain  by  which 
the  disease  is  accompanied.  As  a  rule, 
the  cornea  is  affected  earlv  in  the  af- 


fection, either  by  ulceration  or  diffuse 
infiltration. 

Etiology. — The  disease  is  of  specific 
origin,  and  the  constant  presence  of 
Loffier's  bacillus  has  lead  to  the  assump- 
tion of  this  germ  being  the  causal  factor 
in  the  diphtheritic  process. 

Children  between  the  ages  of  two  and 
eight  years  are  usually  affected,  both 
eyes  being  involved.  The  disease  is  rare 
in  this  country,  but  is  not  infrequent 
abroad,  where  it  occurs  in  an  epidemic 
form.  The  prognosis  is  decidedly  grave 
on  account  of  the  tendency  toward  cor- 
neal involvement. 

Treatment. — In  the  first  stage,  when 
the  lids  are  hard  and  board-like,  and 
there  is  a  necessity  of  limiting  the 
amount  of  exudation,  ice-compresses 
should  be  employed,  but  hot  compresses 
are  indicated  as  soon  as  the  cornea  shows 
signs  of  involvement.  Treatment  must 
be  tentative.  Mild  antiseptic  lotions 
should  be  employed  to  remove  all  secre- 
tions, either  bichloride  of  mercury  (1  to 
8000)  or  potassium  permanganate  in  2- 
per-cent.  solution.  Silver  nitrate  is  con- 
tra-indicated in  the  early  stages,  but 
may  be  utilized  when  the  membrane 
comes  away.  Atropine  should  be  in- 
stilled early  on  account  of  the  tendency 
to  corneal  involvement.  Great  attention 
should  be  directed  toward  building  up 
the  general  health.  Mercury  and  quinine 
should  be  administered  and  stimulants 
ordered  if  the  child  shows  signs  of  col- 
lapse. The  isolation  of  the  patients  is 
necessary  to  prevent  further  contagion. 

Treatment  by  antitoxin  of  25  cases 
of  diphtheritic  conjunctivitis  occurring 
among  SOOO  cases  of  diphtheria  at  the 
Boston  City  Hospital.  In  nil  these  eases 
the  Klebs-Loffler  bacillus  was  present 
in  the  discharges  from  the  nose.  Eight 
cases  were  admitted  for  ocular  diph- 
theria; the  others  were  faucial  diph- 
theria  which   had   incidcntallv  a   mem- 


304 


COXJUXCTIVA.    TUBERCtJLAK  DISEASE.    LUPUS. 


brace  on  the  conjunctiva.  All  were 
treated  with  antitoxin,  the  first  dose 
being  4000  units.  Usually  a  second  dose 
of  like  amount  was  given  at  the  end  of 
six  or  eight  hours,  and  some  had  three 
or  four  injections.  Such  cases  in 
twenty-four  hours  usually  were  doing 
well,  and  after  forty-eight  hours  no 
more  anxiety  was  felt  for  the  eyes.  In 
those  cases  in  which  there  were  corneal 
ulceration  the  antitoxin  favorably  af- 
fected the  corneal  lesion,  and  with  the 
exception  of  4  cases  the  patients  left 
the  hospital  with  good  vision.  In  1  of 
these  4  cases  the  cornea  upon  admission 
seemed  to  be  wholly  necrotic.  Six 
months  later  there  was  considerable 
vision.  An  opaque  scar  occupied  ap- 
proximately half  the  cornea.  In  the  3 
other  cases  every  cornea  was  lost. 
These  3  patients  had  diphtheritic  infec- 
tion during  an  attack  of  measles.  This 
probably  accounted  for  the  severity  of 
the  corneal  process.  M.  Standish  (Bos- 
ton Med.  and  Surg.  Jour.,  Oct.  2,  1902). 

Tubercular  Disease  of  the  Conjunctiva. 

Symptoms. — Tubercular  disease  of  the 
conjunctiva  may  be  either  present  itself 
as  a  primary  or  a  secondary  manifesta- 
tion; in  either  event  it  is  an  extremely 
rare  disease.  In  both  varieties  the  dis- 
ease occurs  in  the  form  of  small,  yellow- 
ish-gray nodules  on  the  palpebral  con- 
junctiva. These  break  down  and  form 
ulcers  with  uneven  and  indurated  edges. 
The  floors  of  these  ulcers  have  either 
a  lardaceous  appearance  or  are  covered 
with  grayish-red  granulations.  The  con- 
junctiva is  swelled  and  turgid,  the  lids 
are  thickened,  and  there  is  considerable 
discharge.  The  bulbar  conjunctiva  and 
the  cornea  may  become  afTected,  and  in 
severe  cases  the  ulcers  on  the  palpebral 
conjunctiva  may  burrow  down  and  in- 
volve the  entire  thickness  of  the  lid. 
Although  this  gives  a  clinical  picture 
which  is  almost  characteristic,  the  diag- 
nosis may  be  verified  by  the  discovery 
of  the  tubercle  bacillus  in  tlie  contents 
of  the  ulcers. 


Case  of  tubercle  of  the  conjunctiva  in 
a  boy  15  years  of  age.  The  condition  re- 
sembled that  of  trachoma;  the  mem- 
brane was  greatly  shrunken  and  the  eye- 
ball was  atrophic.  ^Xicroscopical  study 
showed  giant-cells,  but  no  bacilli.  Rob- 
erts (Brit.  Med.  Jour.,  June  10,  '93). 

Conjunctival  tuberculosis  may  closely 
simulate  trachoma.    In  one  case  a  micro- 
scopical examination  of  a  piece  of  the 
conjunctiva  was  necessary  before  an  ex- 
act diagnosis  could  be  made.    H.  Heiners- 
dorff    (Klin.   Monats.  f.  Augenh.,   Mar., 
■9S). 
The  disease  usually  affects  but  one  eye 
and  occurs  almost  witliout  exception  in 
the  young.     It  manifests  a  great  tend- 
ency to  recur,  and  may  become  the  start- 
ing-point of  general  tuberculosis. 

Etiology. — As  a  rule,  tubercular  con- 
junctivitis is  a  primary  disease  and  orig- 
inates in  a  direct  infection  of  the  con- 
junctiva. When  the  disease  occurs  as  a 
secondary  manifestation,  it  is  usually 
transmitted  from  the  nasal  or  pharyngeal 
mucous  membrane  by  means  of  the  lacry- 
mal  passages. 

Treatment. — This  should  consist  in 
the  removal  of  all  the  diseased  structure 
if  the  process  be  localized,  by  the  curette, 
knife,  or  galvanocautery;  but,  if  the  in- 
volvement of  the  ocular  structure  be  dis- 
seminated, enucleation  should  be  in- 
stantly performed. 

Case  of  undoubted  primary  tubercu- 
losis of  the  palpebral  conjunctiva,  veri- 
fied by  the  finding  of  a  few  Koch  bacilli. 
Tlie  eye  in  other  respects  remained  un- 
involved.  The  palpebral  ulceration  was 
treated  and  cured  by  frequent  application 
of  silver  nitrate,  bathing  with  saturated 
solution  of  potassium  chlorate,  and  cu- 
rettage. The  patient  died,  two  years 
later,  from  laryngeal  and  pulmonary 
phthinis.  II.  Arinaignac  (Ann.  d'Oculist., 
Aug.,  '97). 

Lupus  of  the  Conjunctiva. 

Conjunctival  ulcers  occurring  in  this 
disease  are  distinguishable  from  tuber- 
cular ulcers  chiefly  by  the  fact  that  they 


CONJUNCTIVA.    PEMPHIGUS.    SYPHILITIC  DISEASE.    TUMORS. 


305 


have  involved  the  conjunctiva  from  the 
skin,  instead  of  from  the  mucous  mem- 
brane, and,  like  cutaneous  lupus,  they 
undergo  spontaneous  healing  in  one 
place,  while  the  ulcer  keeps  advancing 
in  another.  The  disease  occurs  either 
as  a  primary  process  or  as  an  extension 
of  the  disease  from  the  surrounding 
skin.  It  appears  as  an  ulcer,  the  bottom 
of  which  is  covered  with  granulations, 
which  bleed  on  the  slightest  touch  and 
are  filled  with  tubercle  bacilli. 

Treatment  consists  in  thorough  re- 
moval of  the  contents  of  the  ulcer  with 
a  curette,  followed  by  careful  cauteriza- 
tion. 

Pemphigus. 

Pemphigus  of  the  conjunctiva  is  a 
very  rare  affection,  and  is  usually  seen 
in  connection  with  pemphigus  vulgaris 
of  other  parts  of  the  body,  although  it 
may  occur  as  an  independent  disease. 
BullaB  form  upon  the  conjunctiva  and 
are  attended  with  pain,  photophobia, 
and  lacrymation.  The  blisters  break 
down  and  form  cicatrices  in  the  conjunc- 
tiva. Eepeated  recurrence  is  the  rule,  so 
that  the  membrane  finally  becomes  much 
shrunken  and  atrophied,  and  appears 
dry,  smooth,  and  tense.  The  cornea  be- 
comes cloudy  and  the  lids  are  frequently 
distorted,  aggravating  the  symptoms  by 
the  displacement  of  the  cilia  which  this 
occasions. 

Treatment  is  of  no  avail,  though  the 
condition  may  be  mitigated  by  emoll- 
ients, and  protection  from  the  light  and 
air  by  coquillos.  Arsenic  may  be  admin- 
istered internally. 

Syphilitic  Disease  of  the  Conjunctiva. 

Chancres  about  the  eye,  as  a  rule,  de- 
velop on  the  edge  of  the  lids;  they  may 
also  be  observed  on  the  palpebral  con- 
junctiva and  rarely  on  that  of  the  globe. 
The  disease  is  usually  transmitted  by 
kissing.    At  times,  however,  nJcers  mav 


form  from  the  breaking-down  of  gum- 
mata  of  the  conjunctiva. 

Instance  of  a  syphilitic  ulcer  of  the 
bulbar  conjunctiva.  The  initial  )Bsion 
had  occurred  eighteen  months  previously. 
Under  general  antisj'philitic  measures 
the  local  manifestation  disappeared 
promptly.  Fromaget  (Gaz.  Hebd.  dea 
Sciences  !Med.  de  Bordeaux,  Aug.  0,  '93). 

Case  of  mucous  patch  of  the  conjunc- 
tiva complicated  by  a  pseudomembranous 
formation  in  a  woman,  20  years  of  age, 
who  exhibited  other  secondary  lesions  of 
syphilis.  The  conjunctiva  of  the  lower 
eyelid  was  swelled  and  congested  and 
covered  by  a  pseudomembranous  exudate. 
Schwartzschild  (Med.  Eec,  Apr.  22,  '93). 

Tumors  of  the  Conjunctiva. 

Tumors  of  the  conjunctiva  may  be 
both  malignant  and  benign. 

Dermoid. — The  most  common  among 
the  latter  is  the  dermoid,  which  is 
always  congenital  and  is  often  found 
associated  with  wart-like  growths  from 
the  skin  in  front  of  the  ears,  and  with 
harelip.  They  are  ascribed  to  an  arrest 
of  development.  They  occur  as  pale- 
yellow  rounded  or  oval  bodies  the  size  of 
a  split  pea,  usually  at  the  extreme  limbus 
of  the  cornea.  Their  surface  is  dry  and 
smooth  and  frequently  has  a  few  hairs 
projecting  from  it. 

If,  as  sometimes  happens,  the  growth 
shows  a  tendency  to  involve  the  cornea 
or  cause  irritation,  it  should  be  excised, 
care  being  taken  to  avoid  injuring  the 
deeper  layers  of  the  cornea. 

Polyp  is  a  benign  pediculated  growth 
of  the  conjunctiva,  which  is  but  rarely 
seen.  It  is  usually  very  small  and  is 
found  in  conjunction  with  the  caruncle. 

P.\piT,LOMATA  are  occasionally  con- 
founded with  polypi,  but  may  be  readily 
distinguished  from  them  by  their  rough. 
raspberry-like  surface.  They  may  be 
pediculated  or  sessile.  Both  forms  of 
growths  may  be  readily  removed  with 
scissors. 


2—20 


306 


CONJUNCTIVA.    MISCELLANEOUS  DISORDERS. 


AxGiOiiATA  are  rare,  but  when  they 
occur  are  usually  found  in  association 
with  a  caruncle.  They  are  congenital, 
but,  as  they  usually  increase  in  size  after 
birth,  their  removal  is  usually  demanded. 

The  conjunctiva  is  rarely. the  seat  of 
malignant  tumors,  but  both  epithelioma 
and  sarcoma  may  occur.  They  both 
arise  from  the  tissue  at  the  limbus. 

Epithelioma  of  the  conjunctiva  is 
non-pigmented,  and  occurs  as  a  flat,  red- 
dish tumor  with  a  broad  base.  The 
tumor  slowly  increases  in  size,  involving 
the  cornea  like  pannus,  and  is  prone  to 
ulceration. 

Saecoma  is  usually  pigmented  and 
may  attain  large  size,  the  growth  being 
at  times  very  rapid.  They  rarely  attack 
the  cornea. 

The  early  removal  of  both  of  these 
forms  of  growth  is  imperative,  to  pre- 
vent implication  of  the  other  structures 
of  the  eye.  Enucleation  is  frequently 
demanded. 

Subconjunctival  sarcoma  removed  from 
a  patient  62  years  old.    Four  years  later 
there  was  not  a  trace  of  recurrence  or 
metastasis.    K.  Joerss  (Beit.  z.  Augenh., 
Jan.,  '98). 
.     Cysts. — Simple  cysts  of  the  conjunc- 
tiva are  very  uncommon.    They  appear 
as  translucent  spherical  bodies  the  size 
of  a  pea,  usually   on   the  bulbar  con- 
junctiva, and  may  be  regarded  as  dilated 
lymphatic  vessels. 

Cysticercus.  —  Subconjunctival  cys- 
ticercus  is  also  an  extremely  rare  affec- 
tion. It  may  be  distinguished  from  the 
foregoing  by  the  fact  that  it  may  be 
readily  moved  under  the  conjunctiva, 
while  simple  cyst  cannot,  as  a  rule,  be 
moved  from  its  position.  The  diag- 
nostic point,  however,  is  the  presence  of 
a  round,  white,  opaque  spot  on  the  ante- 
rior surface  of  the  tumor,  the  recep- 
laculvm  of  the  cyst.  Excision  of  the 
growth  by  dissection  is  indicated. 


Miscellaneous  Disorders  of  the  Con- 
junctiva. 

Conjunctival  Ecchymosis.  —  This 
may  be  originated  by  traumatisms  or 
violent  inflammation  of  the  conjunctiva, 
or  may  occur  spontaneously  in  the  aged, 
from  brittle  blood-vessels,  and  in  chil- 
dren in  association  with  disease  attended 
by  spontaneous  hjemorrhage  elsewhere, 
particularly  after  whooping-cough. 

The  meshes  of  the  conjunctiva  become 
filled  with  blood  and  the  staining  of  the 
tissues  may  persist  for  some  weeks. 
When  the  ecchymosis  appears  under  the 
conjunctiva  several  days  after  an  injury 
to  the  head,  it  becomes  an  important 
factor  in  the  diagnosis  of  fracture  of 
some  of  the  bones  composing  the  orbit. 

Chemosis. — Chemosis  of  the  conjunc- 
tiva results  when  the  connective-tissue 
layer  is  filled  with  serum,  usually  as  the 
result  of  a  severe  inflammation  of  the 
conjunctiva  or  some  of  the  deeper  ocular 
tissues;  it  may,  however,  appear  spon- 
taneously. 

Lymphangiectasis  of  the  conjunctiva 
occurs  at  times  as  a  small  collection  of 
blisters  on  the  bulbar  conjunctiva,  due 
to  distension  of  the  lymph-channels  as  a 
result  of  interference  with  their  circula- 
tion. It  may  occur  at  any  stage  and  is 
not  significant. 

LiTHiASis  of  the  conjunctiva  consists 
in  the  deposit  of  chalky  matter  in  the 
ducts  of  the  Meibomian  glands,  and 
gives  the  appearance  of  numerous,  small, 
yellowish-white  spots  scattered  through- 
out the  conjunctiva.  As  they  frequently 
occasion  considerable  irritation,  they 
should  be  removed  by  incision. 

Amyloid  disease  of  the  conjunctiva 
is  due  to  a  peculiar  degeneration  of  the 
conjunctiva  in  which  pale-yellowish 
masses  appear  chiefly  on  the  palpebral 
conjunctiva,  but  also  in  the  bulbar  por- 
tion.    The  lids  become  much  swelled 


CONJUNCTIVA.    PTERYGIUM.     SYMPTOMS.    ETIOLOGY.    TREATMENT.      307 


without  the  usual  attendant  signs  of  in- 
liammation.  The  conjunctiva  resembles 
white  wax. 

The  disease  is  primary,  although  it 
may  also  at  times  be  developed  from 
granular  conjunctivitis. 

Treatment  should  consist  in  removing 
sulTicient  of  the  conjunctival  masses  to 
permit  of  greater  freedom  in  the  move- 
ments of  the  lids,  which  are  often  much 
restricted,  and  to  gain  better  vision. 

Pinguecula  is  a  small,  yellowish  ele- 
vation in  the  bulbar  conjunctiva  near  the 
corneal  limbus  and  usually  situated  to 
the  inner  side.  It  is  composed  of  con- 
nective tissue  and  elastic  fibres,  in  asso- 
ciation with  a  colloid  substance;  it  is 
due  to  the  action  of  external  irritants. 
It  has  no  significance  beyond  its  cosmetic 
effect,  except  that  it  may  originate  pte- 
rygium. 

Pterygium. 

Symptoms. — Pterygium  consists  in  a 
triangular  fold  of  hypertrophied  con- 
junctival and  subconjunctival  tissue  of 
fleshy  appearance,  generally  situated  to 
the  inner  side  of  the  cornea  in  the  pal- 
pebral fissure.  It  may,  however,  be  on 
the  outer  side  of  the  cornea  and  in  the 
traumatic  variety  may  entirely  surround 
the  membrane.  The  apex  of  the  triangle 
or  the  head  of  the  growth  is  attached  to 
the  cornea,  while  the  base  spreads  out 
like  a  fan  into  the  semilunar  fold.  The 
neck  of  tlie  growth  lies  between  the  apex 
and  the  base  and  corresponds  to  that 
part  which  lies  on  the  limbus. 

At  times  the  pterygium  may  push  ita 
way  across  the  cornea  and  disturb  vision 
by  involving  the  pupillary  area  of  that 
membrane.  But  usually,  however,  it 
shows  no  tendency  to  advance  into  the 
cornea. 

In  its  early  stages  the  growtli  is  thick 
and  fleshy  in  appearance;  but  it  becomes 
paler  after  a  time  and  its  blood-vessels 


are  reduced  to  fibrous  cords,  giving  the 
structure  a  tendinous  appearance. 

Pseudopterygium  may  always  be  diag- 
nosed from  the  true  variety  by  the  fact 
that  a  probe  may  be  passed  under  the 
neck  of  the  latter,  whereas  this  proced- 
ure is  impossible  in  pseudopterygium, 
owing  to  the  matting  togetlier  of  the  tis- 
sues by  the  preceding  inflammation. 

Etiology. — Pterygium  never  occurs  in 
children,  although  it  is  not  an  uncom- 
mon disease  of  adult  life.  Fuchs  thinks 
that  its  starting-point  is  usually  a  pre- 
existing Pinguecula,  and  that  it  is  due 
to  the  prolonged  influences  to  which  the 
conjunctiva  in  the  region  of  the  palpe- 
bral fissure  is  exposed.  It  is  especially 
common  among  persons  who  are  sub- 
mitted to  the  inclemencies  of  the 
weather:  sailors,  coachmen,  farmers,  and 
others. 

Pseudopterygium,  or  traumatic  pteryg- 
ium, occurs  as  a  result  of  some  inflam- 
matory process  which  causes  a  lesion  of 
the  margin  of  the  cornea.  This  variety 
is  especially  liable  to  form  after  burns  or 
marginal  ulceration  occurring  in  puru- 
lent conjunctivitis  or  phlyctenular  dis- 
ease. 

Treatment. — If  the  pterygium  be  small 
and  shows  no  tendency  to  involve  the 
cornea,  it  should  be  allowed  to  remain, 
for  its  removal  for  cosmetic  purposes  will 
be  unsatisfactory,  owing  to  the  scar 
which  remains  upon  the  cornea  and  con- 
junctiva. 

A  pterygium  may  be  removed  either 
by  excision  or  by  ligature.  In  the 
former  method  the  head  of  the  growth  is 
grasped  with  fixation-forceps  and  is  dis- 
sected off  from  the  cornea  by  a  sharp 
knife.  This  being  accomplished,  the 
growth  should  be  separated  from  its  base 
by  two  converging  incisions.  After  tiie 
removal  of  the  pterygium,  the  edge  of 
the  wound  should  be  carefully  united  by 


308 


COXJUXCTIVA.     INJURIES 


sutures.  If  the  growth  be  very  large,  it 
may  be  split  into  an  upper  and  lower 
haK  after  its  dissection  from  the  cornea, 
and  the  flaps  thus  obtained  transplanted 
into  the  superior  and  inferior  cid-de-sacs. 

Electrolysis  is  of  value  in  the  early 
stages  of  pterygium,  in  a  strength  of  3 
milliamp6res,  the  needle  (connected  with 
the  positive  pole)  being  inserted  at  right 
angles  to  the  axis  of  the  growth.  H.  M. 
Starkey  (Jour.  Amer.  Med.  Assoc.,  Sept. 
17,  '98). 

A  simple  procedure  in  the  treatment 
of  pterygium  described  by  A.  Coe  is  cau- 
terization of  the  head  of  the  membrane 
by  means  of  a  platinum  wire,  with  a  fine 
bulbar  end,  not  larger  than  a  very  small 
pea,  and  heated  in  an  alcohol-lamp. 
Practically  complete  cure  obtained  in  an 
extensive  pterygium  by  three  cauteriza- 
tions of  this  kind,  carried  out  at  inter- 
vals of  a  few  days.  At  the  end  of  sev- 
eral months  it  was  possible  to  make  out 
only  a  light  opacity,  corresponding  with 
the  thickening  in  the  conjunctiva,  while 
the  nearer  tissues  were  entirely  trans- 
parent. The  same  treatment  in  24 
cases,  with  invariably  good  results,  ex- 
cepting in  one  patient,  who  presented  a 
very  extensive  pterygium  with  large 
vascularities.  F.  B.  Loring  (Semaine 
MCd.,  No.  34,  1002). 

Injuries  of  the  Conjunctiva. 

FouEiGN  Bodies. — Small-sized  foreign 
bodies  frequently  make  their  way  into 
the  conjunctival  sac  and  cause  consider- 
able pain  by  the  pressure  which  they 
e.xert  upon  the  cornea  with  every  move- 
ment of  the  lid.  If  the  body  be  found 
imbedded  in  the  lower  cul-de-sac,  it  is 
an  easy  matter  to  remove  it,  but  if  it  be 
under  the  upper  lid,  it  is  necessary  to 
evert  the  latter.  This  is  accomplished 
by  grasping  the  lashes  and  the  edge  of 
the  lid  with  the  thumb  and  forefinger  of 
the  right  hand  while  the  patient  is  di- 
rected to  remain  looking  down,  slightly 
pressing  upon  the  upper  edge  of  the 
tarsus  either  with  a  finger  of  the  other 


hand  or  some  convenient  instrument:   a 
blunt  pencil,  a  probe,  etc. 

Large  bodies  may  remain  buried  deep 
in  the  cul-de-sacs  for  weeks  at  a  time, 
and  merely  cause  the  symptoms  of  a 
chronic  catarrhal  conjunctivitis.  Of 
this  nature  is  the  inflammation  set  up 
by  the  "eye-stones"  which  are  frequently 
introduced  into  the  eye  by  laymen  to 
remove  cinders  or  other  foreign  bodies. 
Having  performed  their  function,  they 
become  imbedded  in  the  folds  of  the  con- 
junctiva. 

"Wounds. — The  conjunctiva  is  not  in- 
frequently involved  in  wounds  of  the 
globe  itself  or  of  its  adnexa.  If  the 
wound  be  extensive,  the  edges  should  be 
approximated  with  stitches,  but  other- 
wise a  simple  boric-acid  wash  with  a  pro- 
tective bandage  will  suffice. 

Burns. — Burns  of  the  conjunctiva  are 
common.  These  are  tisually  caused  by 
lime,  acids,  hot  water,  hot  ashes,  molten 
metal,  etc.,  and  are  particularly  serious 
on  account  of  the  subsequent  contrac- 
tions and  deformities  which  they  occa- 
sion in  the  lids  and  damage  wrought  in 
the  cornea. 

If  the  substance  inflicting  the  burn  is 
lime,  the  eye  should  be  washed  with  a 
diluted  or  weak  solution  of  a  mineral 
acid,  or,  if  this  be  not  at  hand,  all  parti- 
cles should  be  removed  at  once  by  forci- 
bly flooding  the  eye  with  water  from  a 
hose  or  spigot. 

If  an  acid  has  caused  the  burn,  it 
should  be  neutralized  by  a  weak  solution 
of  borax,  bicarbonate  of  soda,  or  of  com- 
mon salt  if  nothing  else  be  on  hand. 

Subsequent  inflammation  is  best  com- 
bated by  cold  compresses,  boric  acid, 
atropine,  and  some  emollient  substance, 
such  as  vaselin. 

Wm.  CAMrnELL  Posey, 

Pliiladelphia. 


CONSTIPATION.     SYMPTOMS. 


309 


CONSTIPATION.  —  Lat.,  constipatis 
(from  constipare,  to  pack  together). 

Definition. — Prolonged  retention  of 
fjeces  in  the  alimentary  canal;  retarded 
defecation;  a  symptom  resulting  from  a 
variety  of  morbid  conditions  of  the  in- 
testines, and  not  a  distinct  disease.  The 
strictly-natural  law  governing  intestinal 
evacuations  in  man  requires  one,  and 
sometimes  two,  discharges  every  twenty- 
four  hours. 

Symptoms. — The  symptoms  produced 
by  habitual  constipation  vary  much  in 
different  cases.    Many  persons  appear  to 
enjoy  fair  health  with  an  evacuation  only 
once  in  two  or  three  days.     A  smaller 
number  continue  well  with  only  an  evac- 
uation once  a  week;    one  woman  came 
under  my  observation  who  claimed  to 
have  had  no  faecal  discharge  from  the 
bowels  for  thirty  days,  and  yet  had  been 
attending  to  her  household  duties  all  the 
time,  with  only  a  sense  of  fullness  in  the 
abdomen  and  some  dizziness  in  her  head. 
Case  of  Hindoo  male,  aged  50  years,  5 
feet  6  inches  liigli,  who  has  been,  since  his 
30th  year,  in  the  habit  of  passing  stools 
once  in  six  months  or  so,  and  even  then 
only    two    or    three    hard    scybala    are 
passed.    But  every  eight  months  the  man 
gets  a  severe  attack  of  fever,  preceded  by 
rigors,  and  then  he  passes,  to  his  entire 
relief,    sometimes     consciously    and    at 
others  in  an  unconscious  state,  enormous 
quantities   of   black,   semisolid,   feculent 
matter,    which    has    evidently    been    ac- 
cumulating in  his  intestines  all  the  while. 
Notwithstanding  all  this,  the  man  looks 
well  and  healthy.     He  suffers  very  little 
from  this  e.xcopt  a  slight  loss  of  appetite 
and  energy.    His  abdomen  is  not  bloated, 
but  feels  hard  on  pressure.    He  does  not 
complain    of    flatulence;     passes    urine 
freely;     and  sleeps  well.      S.     Kotayya 
Naidie   (Indian  Med.  Rep.,  May  1,  '90). 

In  a  large  majority  of  persons,  how- 
ever, constipation  causes  a  sense  of  full- 
ness, lassitude,  mental  depression,  or  dull 
pain  in  the  head,  with  some  impairment 


of  digestion,  all  of  which  symptoms  are 
temporarily  removed  by  a  free  movement 
of  the  bowels.  In  some  cases  after  re- 
tention of  the  intestinal  contents  from 
three  to  five  days,  a  spontaneous  diar- 
rhoea supervenes  for  a  single  day,  after 
which  the  constipation  returns  as  before. 
In  many  other  cases,  protracted  constipa- 
tion leads  to  a  violent  attack  of  head- 
ache every  week  or  ten  days,  accom- 
panied by  extreme  nausea  or  vomiting  for 
a  day,  during  which  the  bowels  are  evacu- 
ated, and  the  next  day  the  patient  re- 
turns to  his  ordinary  duties,  though  pale 
and  impaired  in  strength. 

Most  of  the  dyspeptic  conditions,  dila- 
tion of  the  stomach,  etc.,  are  really  cases 
of  constipation,  and  this  may  mechan- 
ically tend  to  produce  haemorrhoids, 
hernias,  vesico-uterine  tumors,  hyper- 
trophy of  the  prostate,  etc.  Germain 
S6e  (Med.  Rec,  Feb.  3,  '94). 

Hysteria  in  the  female  and  hypochon- 
dria in  the  male,  or  even  conditions  bor- 
dering on  insanity,  may  be  the  result  of 
constipation.  Staple  (Amer.  Med.-Surg. 
Bull.,  Aug.  15,  '94). 

In  many  cases  the  middle  and  posterior 
part  of  the  tongue  is  covered  with  a  light 
coat  and  the  urine  is  deeper  color  and 
less  in  quantity  than  natural;  the  appe- 
tite is  variable.  Sometimes  the  colon 
is  distended  with  gases,  with  slight  ten- 
derness on  pressure  and  irregular  peri- 
staltic movements.  In  such  cases  the 
operation  of  physic  is  liable  to  be  accom- 
panied by  pains  across  the  abdomen  and 
tenesmus,  and  some  mucus  may  be  evacu- 
ated with  the  faeces.  Such  symptoms  in- 
dicate congestion  or  inflammation  in  the 
mucous  membrane  of  the  rectum,  which 
is  sufficient,  in  some  cases,  to  cause  fre- 
quent slimy  discharges,  while  the  ascend- 
ing and  transverse  colons  remain  filled 
with  compact  focces. 

Many  cases  of  constipation  are  treated 
unsatisfactorily  with  medicine  when  the 
real  cause  is  in  the  rectum.     The  pres- 


310 


COXSTIPATIOX.    DIFFERENTIAL  DIAGNOSIS. 


ence  of  thickening  of  the  skin  and 
mucous  membrane,  irritable  ulcer  or  fis- 
sure, fistula,  or  hsemorrhoids  frequently 
interfere  with  the  treatment  instituted. 
W.  il.  Beach  (Pittsburgh  Med.  Kev., 
June,  '95). 

A  narrowing  of  the  ileo-ctecal  valve  is 
the  cause  of  certain  caseS  of  obstinate 
constipation.  W.  J.  Mayo  (Annals  of 
Surg.,  Sept.,  1900). 
Differential  Diagnosis. — Simple  reten- 
tion of  the  fffical  contents  of  the  in- 
testines longer  than  natural  may  be 
considered  as  sufficient  diagnostic  evi- 
dence of  constipation  in  an  tmqualified 
sense.  But  as  undue  retentions  of  faces 
are  often  caused  by  a  variety  of  mechan- 
ical obstructions,  such  as  strictures,  in- 
vaginations, concretions,  morbid  growths 
or  tumors,  and  visceral  displacements, 
all  these  have,  by  common  consent,  been 
classed  as  intestinal  obstructions,  while 
the  words  "costiveness"  and  "constipa- 
tion" are  properly  made  applicable  only 
to  such  cases  as  depend  upon  failure  of 
one  or  more  of  the  physiological  condi- 
tions on  which  regular  intestinal  evacu- 
ations depend. 

Differential  diagnosis  involves,  first, 
proof  of  the  absence  of  mechanical  ob- 
structions, and,  second,  proof  that  the 
physiological  conditions  concerned  in 
natural  evacuations  are  at  fault  in  any 
given  case.  In  all  cases  of  intestinal 
obstruction  the  pains,  distension,  and 
tenderness  are  uniformly  manifested  at 
some  one  part  of  the  abdomen  or  pelvis. 
If  the  obstruction  is  from  the  pressure  of 
tumors  or  morbid  growths  these  can  gen- 
erally be  detected  by  proper  physical  ex- 
amination of  the  abdomen. 

If  from  stricture  or  invagination  there 
will  be  not  only  well-marked  pains  and 
fullness  at  some  one  location,  but  in 
strictures,  especially,  the  past  history  of 
the  patients  will  show  them  to  have  been 
the  scquelic  of  dysentery,  typhoid  fever, 
or  some  form  of  primary  intestinal  ulcer- 


ation. Obstructions  by  uterine  displace- 
ments or  rectal  concretions  are  readily 
detected  by  direct  examinations  through 
the  vagina  and  rectum. 

[A  result  of  chronic  constipation  often 
seen,  which  may  not  only  simulate,  but 
also  cause  uterine  trouble,  is  enlargement 
and  pouching  of  the  lower  third  of  the 
rectum.     This   condition   is   found   very 
frequently  in  virgins,  and  gives  the  pain 
in  the  back,  discomfort  in  standing  or 
walking  (more  particularly  in  standing), 
and  the  sensations  of  dragging  and  full- 
ness, as  if  the  parts  would  fall.     This 
is  due  to  the  distension  and  varicosity 
of  the  vaginal  and  uterine  veins,  caused 
by  the  formation  of  a  proctocele,  press- 
ing the  vagina  forward.     Efl'orts  in  def- 
ecation then   cause  intense  pain,  press- 
ing tlie  vagina  and  rectum  downward  to 
the  pubis  and  perineum ;   instead  of  re- 
lieving the  patient,  however,  the  traction 
on  the  vagina  forces  the  uterus  down- 
ward, and  prolapsus  or  retroversion  re- 
sults.    In  this  condition,  the  correction 
of  the  retroversion  does  not  relieve  the 
patient,  since  the  cause  is  not  the  retro- 
version,  but   the   rectocele,   due   to   the 
constipation.    The  proper  course  to  pur- 
sue is  to  cure  the  constipation,  when  the 
reposition   of  the   uterus   will   cure   the 
symptoms.    Charles  B.  Kelsey,  Assoc. 
Ed.,  Annual,  '92.] 
Constipation  not  caused  by  mechan- 
ical obstruction  may  result  from   im- 
pairment or  suspension  of  the  natural 
peristaltic  motion  of  the  intestines,  and 
from  paralysis  of  the  nerves  of  the  rectum 
concerned  in  the  act  of  defecation,  from 
irregular    contractions    of    the    circular 
fibres  of  the  muscular  coat  by  which 
regular  peristalsis  is  prevented,  from  the 
reversing  influence  of  continuous  nausea, 
from  excessive  obesity  coupled  with  loss 
of  tone  in  the  abdominal  muscles,  and 
from  deficient  mucous  and  glandular  se- 
cretions, by  which  the  faces  are  per- 
mitted to  become  dry  and  hard.    In  all 
these  cases  a  careful  manual  examination 
of  the  abdomen  will  detect  the  presence 
of  fjccal  accumulations  in  different  parts 


CONSTIPATION.    ETIOLOGY. 


311 


of  the  colon  and  rectum.  And  their  loca- 
tion will  vary  from  day  to  day,  instead  of 
uniformly  appearing  in  the  same  place, 
as  in  cases  of  obstruction. 

Etiology.  —  Habitual  constipation  is 
more  frequent  in  adults  than  in  children, 
and  more  frequent  in  females  than  in 
males.  Probably  the  most  efficient  causes 
of  constipation  are  sedentary  in-door 
habits  with  deficient  out-door  muscular 
exercise.  The  first  necessarily  lessens  the 
efficiency  of  respiration  and  internal  dis- 
tribution of  oxygen,  thereby  lessening 
the  tone  and  activity  of  the  nervous  and 
muscular  structures  generally;  and  the 
omission  of  the  latter  still  further  lessens 
tissue-metabolism  and  excretory  proc- 
esses. If  we  add  to  the  foregoing  the 
depression  of  the  transverse  colon  and 
the  crowding  of  the  abdominal  and  pelvic 
viscera  down  upon  the  rectum  by  well- 
known  female  habits  of  dress,  we  will 
have  the  chief  causes  why  females  suffer 
much  more  from  constipation  than  the 
male  sex. 

There  is,  beyond  doubt,  a  form  of 
habitual  constipation  in  which  there  is 
either  diminished  irritability  of  the  in- 
testinal nerves  or  defective  development 
in  the  muscular  coat  of  the  intestine; 
an  hereditary  factor  is  often  present.  It 
may  be  acquired  through  habit  of  sup- 
pressing the  desire,  insufficient  diet,  or 
abundant  diet  difficult  to  digest,  deficient 
in  water,  or  too  easily  absorbed.  Seden- 
tary habits  are  also  a  cause,  but  obsti- 
nate habitual  constipation  may  occur 
even  in  those  who  lead  an  active  life. 
Disturbances  in  the  circulation — as  in 
heart  disease,  mechanical  pressure,  and 
particularly  pregnancy — may  produce  it; 
but  displacement  of  the  bowel,  such  as 
occurs  in  GlCnard's  disease,  is  of  doubt- 
ful inducncc.  Adhesion  of  coils  of  in- 
testine together,  or  to  some  other  organ, 
is  an  occasional  cause.  The  relation  of 
constipation  to  mental  disturbance  is 
well  known,  and  the  theory  of  intestinal 
intoxication,  also,   cannot  be  set  aside. 


Prognosis,  as  a  rule,  is  unfavorable. 
Ewald  (Berl.  klin.  Woch.,  Mar.,  '97). 

It  is  generally  recognized  that  wo- 
men for  various  reasons  are  most  sub- 
ject to  constipation;  nevertheless  rectal 
constipation,  from  which  a  large  num- 
ber suffer,  has  received,  at  the  hands  of 
the  profession,  scant  consideration. 

Eectal  constipation  may  be,  but  is 
rarely,  due  to  a  nervous  condition — i.e., 
ner\'ous  rectum.  ^Miile  it  may  occur 
as  the  result  of  inflammatory  condi- 
tions, such  as  haemorrhoids,  fistulse,  and 
fissures,  which  are  common  to  men  and 
women  alike,  in  very  many  cases  it  is 
occasioned  because  of  the  peculiar  an- 
atomical construction  of  the  parts,  an<l 
is  mechanical  in  its  origin.  Antever- 
sions,  retrodisplacemcnts,  neoplasms 
(especially  fibroids),  and  periuterine  in- 
flammations obstruct  the  downward 
passage  of  the  feeces.  Conversely,  ow- 
ing to  the  close  juxtaposition  of  the 
rectum  and  the  genital  organs  of  the 
woman,  a  loaded  rectum  in  its  turn 
may  occasion  ovarian  and  uterine  dis- 
placements and  disorders. 

A  form  of  rectal  constipation  which 
heretofore  has  received  but  little  recog- 
nition is  that  which  occasions  and  is 
the  result  of  the  pulling  do\vn  of  the 
recto-vaginal  septum,  thereby  forming 
a  pouch,  constantly  increasing  in  she, 
changing  the  direction  of  the  intra- 
abdominal rectal  pressure  to  that  of 
the  vaginal,  which  is  at  right  angles  to 
it,  and  making  it  diflicult  for  the  rectal 
sphincters  to  rela.x  so  as  to  void  the 
contents  of  the  bowel.  The  result  is 
not  only  to  render  defecation  diflicult, 
but  incomplete.  The  retention  of  ftecal 
matter  causes  rectal  irritation  and 
auto-intoxication.  This  condition  oc- 
curs not  only  in  women  who  have  borne 
children,  but  in  nullipara  and  the  un- 
married, although  not  so  frequently  in 
the  latter. 

As  regards  the  treatment,  cathartics 
may  be  useful  in  those  cases  in  which 
the  obstruction  is  due  to  inflamed  and 
displaced  organs  or  neoplasms,  which 
prevent  the  descent  of  the  contents  of 
the  bowel  and  in  which  the  hardened 
masses  of  the  foeces  press  and  inflame 
the  genital  organs,  but  would  be  useless 


312 


CONSTIPATION.    ETIOLOGY. 


in  those  cases  in  which  there  has  been 
a  displacement  of  the  recto-vaginal 
wall.  In  such  cases,  glycerin  or  gluten 
suppositories,  or  injections  of  small 
amounts  of  olive-oil,  glycerin,  or  sooth- 
ing fluids,  may  be  employed.  The  use 
of  daily  enemata,  as  ordinarily  prac- 
ticed, is  to  be  reprehended  from  every 
point  of  view.  The  use  of  bougies  or 
dilators  may  prove  beneficial.  For  con- 
stipation of  purely  rectal  origin,  mas- 
sage, electricity,  and  measures  designed 
to  improve  peristaltic  action  are  of  no 
avail.  G.  P.  MuiTay  {Medical  Record, 
Aug.  6,  1904). 

Another  very  common  cause  of  con- 
stipation is  the  failure  to  adopt  and  per- 
sistently maintain  a  regular  time  for 
daily  defecation. 

Instead,  many  persons  frequently  re- 
sist a  desire  to  evacuate  at  the  regular 
time  from  pressure  of  other  engagements, 
and  thus  the  nerves  of  the  rectum  be- 
come habituated  to  the  contact  of  faeces 
and  cease  to  renew  the  desire  to  evacuate 
except  at  long  intervals. 

Constipation  generally  results  from  di- 
minished secretion,  atonic  condition,  and 
relaxation  of  abdominal  muscles  depend- 
ent on  sedentary  habits  and  iiTegularity 
in  defecation,  irrational  diet,  or  excessive 
use  of  drugs.  Kress  (Virg.  Med.  Semi- 
Mo.,  Nov.  20,  '97). 

So-called  "dilatation  of  the  colon"  has 
been  enumerated  among  the  important 
causes  of  constipation  both  in  young 
cliildren  and  in  adults. 

Introduction  of  a  largo  quantity  of 
water  into  the  intestine  recommended  in 
order  to  diagnose  a  condition  of  atony 
or  dilatation.  One  to  1 '/,  pints  are  neccs- 
Bary  in  order  to  produce  the  splashing 
Bound  in  the  normal  intestine,  perceptible 
in  the  neighborhood  of  the  tran.sverse 
and  descending  colon;  while  only  '/»  <"■ 
Vo  pint  will  produce  the  sound  if  there  is 
atony  or  dilatation;  and  in  such  a  case 
it  is  perceptible  first  in  the  sigmoid  flex- 
ure, then  in  the  transverse  colon,  and 
finally  in  the  entire  large  intestine. 
Change  of  ponition  produces  a  succussion- 


sound,  and  dilatation  of  the  sigmoid  flex- 
ure may  be  ascertained,  which  may  be 
beyond  the  median  line.  In  the  same 
manner  displacement  of  the  transverse 
colon  may  be  determined,  and  if  simple 
atony  only  is  present  the  spashing  will 
be  heard  in  the  normal  position  of  the 
colon,  while  if  there  is  also  displacement 
the  sound  will  be  heard  under  the  um- 
bilicus. It  is  indispensable  to  evacuate 
the  intestine  with  a  purgative  before 
performing  this  lavage.  In  catarrh  of  the 
intestine  the  water  will  return  charged 
with  mucus  and  false  membrane,  while  if 
the  intestine  is  normal  the  water  will  be 
clear  or  will  contain  only  some  slight 
epithelial  debris.  Boas  (Deutsche  med. 
Zeit.,  Jan.  15,  '95). 

Two  cases  of  "aneurismal"  dilatation 
of  the  colon  as  the  result  of  chronic  con- 
stipation. In  both  cases  the  site  of  the 
tumor  was  the  same:  in  the  last  portion 
of  the  sigmoid  flexure.  The  impaction 
of  fascal  masses  in  this  region  tends  to 
produce  dilatation  behind  it,  and  this 
distension  may  be  localized  or  general. 
General  dilatations  are  relatively  com- 
mon. While  the  condition  of  the  first 
case  could  only  be  accurately  diagnosed 
at  the  time  of  the  operation,  the  great 
mobility  of  the  tumor  which  subse- 
quently developed  itself  in  the  second 
case  gave  rise  to  the  belief  that  in  this 
instance  also  would  a  "pedunculated" 
tumor  be  met  with,  for  on  various  occa- 
sions it  could  be  demonstrated  bimanu- 
ally  that  the  lesser  cavity  of  the  pelvis 
was  absolutely  free,  the  tumor  itself 
being  felt  well  above  the  pelvis.  S.  L. 
Woolmer   (Lancet,  June  10,  1900). 

More  or  less  distension  of  the  colon  is 
a  common  symptom  resulting  from  ac- 
cumulation of  gases  in  nearly  all  the 
cases  of  ordinary  constipation. 

Atony  of  the  intestine  should  be  sepa- 
rated from  chronic  constipation,  which  is 
often  only  a  symptom  of  the  former  con- 
dition. The  atony  usually  alTecta  the 
colon,  which  ia  unable  to  expel  the  freccs. 
It  may  bo  primary,  as  the  result  of  im- 
proper diet,  sedentary  habits,  or  a  too 
frequent  use  of  cathartics;  or  it  may  be 
scciindary  to  many  disorders,  as  obesity, 


CONSTIPATION.    PATHOLOGY.    PROGNOSIS. 


313 


disease  of  the  heart,  lung.s,  or  liver,  ty- 
phoid fever  and  other  intestinal  diseases, 
or  organic  nervous  diseases.  It  is  often 
found  in  childhood  and  may  be  con- 
genital. The  symptoms  are  marked  con- 
stipation, headache,  vertigo,  nausea,  and 
pains  in  the  back  and  loins.  Nervous 
symptoms  are  often  present.  The  signs 
are  marked  tympany  and  sometimes  the 
ability  to  detect  the  distended  colon  and 
fsecal  masses  by  palpation.  Frieden- 
wald  (Med.  News,  Aug.  11,  '94). 

But  dilatation  as  a  primary  patholog- 
ical condition  causing  constipation,  with- 
out having  been  preceded  by  either  in- 
testinal paralysis  or  some  form  of  ob- 
struction, is  certainly  of  rare  occurrence; 
as  recently  shown  by  Mr.  Frederick 
Treves,  who  suggests  "that  the  cases  of 
idiopathic  dilatation  of  the  colon  in 
young  children  are  due  to  congenital  de- 
fects in  the  terminal  part  of  the  bowel," 
and  consequent  obstruction. 

Pathology. — The  various  pathological 
conditions  accompanying  constipation 
have  been  sufficiently  stated  in  connec- 
tion with  its  etiology  and  diagnosis.  Con- 
stipation, when  permitted  to  continue 
several  days,  may  give  rise  to  irritation 
or  inflammation  of  the  mucous  mem- 
brane in  contact  with  the  retained  faeces, 
causing  temporary  diarrhwa  with  pain 
or  tenesmus. 

In  all  cases  of  chronic  constipation 
there  is  a  considerable  degree  of  chronic 
irritation  and  subacute  inflammation  of 
the  crccum  and  colon  and  of  the  sur- 
rounding cellular  tissues;  this  condition 
not  infrequently  becomes  acute,  and  is 
then  recognized  as  an  attack  of  typhlitis. 
The  effect  of  this  subacute  inflammation 
is  rcflexly  to  arrest  peristalsis.  When  a 
purgative  is  administered  in  such  cases, 
peristaltic  movements  are  induced,  the 
irritation  is  increased,  and  after  the 
evacuation  of  the  bowels,  which  is  rarely 
complete,  the  gut  becomes  more  torpid 
than  before.  Nevins  (Brit.  lied.  Jour., 
Dec.  27,  '90). 

One  of  tlic  many  funotions  of  the  ileo- 


cajcal  opening  is  to  prevent  the  too  rapid 
emptying  of  the  small  bowel,  and  to 
maintain  some  pressure  against  peri- 
stalsis until  the  process  of  small  bowel 
digestion  is  properly  finished.  Mayo 
(I3oston  Med.  and  Surg.  Jour.,  May  16, 
1901). 

But  the  more  frequent  result  is  the 
formation  of  septic  materials  and  their 
absorption,  constituting  a  degree  of  auto- 
infection  by  which  the  general  feelings 
of  depression,  loss  of  appetite,  vertigo, 
and  paroxysms  of  sick  headache  are  pro- 
duced. 

Emphasis  upon  the  indolence  of  the 
caecum  occurring  in  children  of  sufficient 
age  to  be  left  considerably  to  themselves. 
They  eat  in  a  careless  manner,  and  fre- 
quently cat  too  much.  The  food  remains 
in  the  C£ecum  and  large  intestine,  giv- 
ing rise  to  such  symptoms  as  headache, 
incapacity  for  study,  paleness,  and  ir- 
regular and  capricious  appetite.  Jules 
Simon  (Revue  GC-n.  de  Clin,  et  de  Ther. 
Jour,  des  Practiciens,  June,  '95). 

Study  of  the  history  of  three  hundred 
cases,  showing  that  about  GO  per  cent,  of 
ail  patients  suft'er  from  constipation,  the 
number  being  proportionately  larger 
among  women.  While  the  colon  and 
rectum  have  not  the  digestive  functions 
formerly  credited  to  them,  their  absorp- 
tive power  is  great  and  the  quantity  ab- 
sorbed is  in  proportion  to  the  time  of 
contact  and  concentration  of  the  sub- 
stance. The  intestinal  system  is  com- 
plex. Since  all  functional  action  in  the 
system  is  reciprocal,  it  follows  that  the 
functional  activity  of  the  chylopoietic 
system  must  affect  the  nutrition  of  the 
brain  and  entire  nervous  system.  The 
absoiplion  of  toxic  and  excrcmentitious 
."lulistances  produces  retrograde  changes 
in  the  quality  of  the  blood,  diminution 
of  the  red  corpuscles,  and,  by  supplying 
an  infected  or  imperfect  nutriment  to 
the  brain,  becomes  a  prominent  factor  in 
the  production  of  cerebral  antemia  and 
nervous  debility.  E.  S.  Pettyjohn  (Med. 
Rec.  May  2:?,  '90). 

Prognosis. — When  constipation  is  the 
result  of  any  form  of  intestinal  obstruc- 


31i 


CONSTIPATIOX.    TREATMENT. 


tion  the  prospect  of  permanent  relief 
will  depend  entirely  on  the  nature  and 
curability  of  the  obstruction  itself.  But 
when  it  depends  upon  the  loss  of  peri- 
staltic action  induced  by  erroneous  habits 
of  life,  the  prognosis  is  very  favorable, 
provided  the  erroneous  habits  of  the  pa- 
tient can  be  permanently  corrected.  All 
such  cases  can  be  temporarily  relieved 
by  suitable  diet,  laxatives,  and  tonic.  Re- 
lapse, however,  will  soon  follow  unless 
all  the  primary  causes  are  persistently 
avoided. 

Treatment. — In  the  treatment  of  all 
cases  of  constipation  the  use  of  active 
cathartics  should  be  avoided  as  far  as 
possible. 

As  few  purgatives  as  possible  should 
be  used.  The  methods  employed  should 
be:  dietetic,  physico-mechanioal,  and 
medicinal.  Such  foods  should  be  used 
as  are  known  to  increase  peristalsis. 
Suitable  massage  is  of  the  greatest  value 
in  many  cases,  but  it  sometimes  fails, 
and  the  same  may  be  said  of  electricity. 
The  usual  position  taken  up  in  defeca- 
tion is  not  the  one  best  adapted  for  emp- 
tying the  rectum.  In  the  use  of  clysters 
particular  attention  should  be  given  to 
tlie  anal  parts  of  the  syringe.  It  should 
be  made  of  vulcanized  caoutchouc,  and 
about  30  to  40  centimetres  long.  The 
disadvantage  of  clysters  is  that  ulti- 
mately small  quantities  of  water  do  not 
suffice,  and  then  large  amounts  must 
be  used;  the  large  intestine  may  thus 
become  ovcrdistended  and  the  injections 
useless.  Regular  attempts  at  defecation 
with  slight  pressure  should  be  made.  An 
efficient  rhubarb  preparation  is  often 
very  useful,  but  it  may  become  neces- 
sary for  the  patient  to  have  constant  re- 
course to  it.  Calomel  is  especially  valu- 
able in  children.  Castor-oil  is  not  suited 
for  constant  use.  In  some  cases,  with  a 
certain  diagnosis  of  ficeal  tumor,  good 
results  are  had  by  combining  croton- 
with  castor-  oil.  Large  injections  of  olive- 
oil  may  very  properly  be  recommended. 
Sometimes  sedative  and  antisjiasmodic 
remedies  are  rcf|iiircd  where  (■<ix\"A\]inU(in 


is  of  the  spastic  type.    Ewald  (Berl.  klin. 
Woch.,  Mar.,  '97). 

Purgatives  excite  increased  secretion  to 
soften  the  ftecal  contents,  and  excessive 
peristalsis  by  which  the  intestine  is  evac- 
uated, but  leave  the  natural  functions  of 
the  intestines  more  exhausted  than  be- 
fore. Consequently,  while  they  afford 
temporary  relief,  they  never  affect  a 
permanent  cure.  To  secure  the  latter, 
the  actual  causes  of  the  constipation  must 
be  ascertained  and  removed. 

Sedentary  habits  must  be  abandoned; 
the  effects  of  in-door  occupations  coun- 
teracted by  special  open  ^air  exercises 
mornings  and  evenings,  sufficient  to  se- 
cure fuP  oxygenation  and  decarboniza- 
tion  of  the  blood;  eating  freely  of  fruit, 
vegetables,  and  coarse  or  brown  bread; 
avoiding  all  use  of  alcoholic  drinks  both 
fermented  and  distilled,  and  instead 
drinking  a  glass  of  natural  laxative  min- 
eral water  each  morning,  and  persistently 
making  an  effort  to  evacuate  the  bowels 
directly  after  breakfast  each  day. 

Reasonable  hydrotherapeutics,  cold  ap- 
plications to  the  abdomen,  and  cold  sitz- 
baths  are  often  of  use;  moderate  exer- 
cise helps,  but  undue  exercise,  by  the 
loss  of  moisture  by  the  akin,  often  in- 
creases the  constipation.  Rosenheim  (In- 
ter. Clinics,  vol.  iv,  '97). 

The  bitter  salines  are  very  valuable, 
and  particularly  Apenta  water,  as  it  is 
especially  indicated  in  atony  of  the 
bowels,  and  has  the  advantage  that  it 
does  not  tend  to  subsequent  constipation. 
Its  action  is  more  gentle  than  that  of 
other  bitter  waters,  because  it  contains 
less  calcium  sulphate  and  no  magnesium 
chloride;  it  is  probably  owed  to  these 
circumstances  that  it  does  not  cause 
cramps.  Bogoslowsky  (Trans.  Moscow 
Soc.  for  the  Preservation  of  Pub.  Health, 
Nov.  C,  '07). 

The  purgatives  and  nlkalinc  mineral 
waters  are  objectionable.  In  place  of 
tlicm  cnemata  and  various  disinfectants 
and  drugs  intended  to  strengthen  the 
niusculiir  aclidii  iif  1lic  irilcHtine  arc  em- 


CONSTIPATION.    TREATMENT. 


315 


ployed.  Strychnine  and  resorcin  are  par- 
ticularly effective.  Boas  (Gaz.  Heb.  de 
Med.  et  de  Chir.,  Jan.  13,  '98). 

Sodium  sulphate,  75  to  150  grains  in 
a  half-glass  of  water  during  the  meal, 
recommended.  Pills  of  aloes  or  of  aloes 
and  cinchona  are  useful.  Massage,  which 
has  for  its  purpose  the  emptying  of  the 
large  intestine,  merits  further  use.  Of 
the  mineral  waters,  Chiltel-Guyon,  Brides, 
and  Aulus  (source  Darmagnac)  are  pre- 
ferred. A.  Robin  (Bull.  G6n.  de  Thf-r., 
lOe  liv.,  p.  593,  '98). 

In  functional  constipation  the  new  lax- 
ative salt  of  lithia,  thialon,  has  given 
success.  A  teaspoonful  should  be  dis- 
solved in  a  cup  of  hot  water  taken  in 
the  morning  on  rising,  while,  at  the  same 
time,  e.xcess  in  nitrogenous  foods  is  to  be 
avoided.  The  remedy  should  be  gradu- 
ally discontinued  as  the  stools  become 
regular.  A.  J.  Jenkins  (Interstate  Med. 
Jour.,  Oct.,  '99). 

To  aid  in  restoring  intestinal  peri- 
stalsis a  pill  or  capsule  may  be  given  each 
night  containing  Vs  grain  of  extract  of 
nux  vomica,  and  1  grain,  each,  of  extracts 
of  cascara  sagrada  and  of  hyoscyamiis. 
If  no  evacuation  takes  place  the  follow- 
ing morning  an  enema  of  warm  water 
may  be  used  soon  after  breakfast. 

Forty-six  grains  of  powdered  boric  acid 
to  be  applied  directly  to  the  rectal  mu- 
cosa. In  eases  where  the  mucosa  cannot 
be  reached,  insufflation  of  the  same  quan- 
tity of  powder  should  be  employed.  In 
from  one-half  to  three  hours  after  the 
application  peristalsis  occurs,  attended 
with  copious  ftecal  evacuations.  Flatau 
(Deutsche  med.  Woch.,  p.  97G,  '90). 

Caffeine  -  chloral  administered  hypo- 
dermically  is  of  value;  injections  of  4 
or  5  grains  dissolved  in  water  recom- 
mended. Ewald  (N.  Y.  Med.  Joui-.,  July 
22,  '93). 

A  tablet  composed  of  nux  vomica  ex- 
tract, podophyllin  resin,  belladonna  ex- 
tract, and  aloin,  '/lo  grain  of  each,  is 
excellent  for  the  average  eases  of  long- 
standing constipation.  The  tablets 
should  be  taken  before  or  after  each 
meal,  and,  if  the  cfTect  is  too  strong, 
half  a  tablet,  more  or  less,  may  be  given, 


never  skipping  a  dose  at  the  regular 
time.  C.  E.  Boynton  (Med.  World,  Oct., 
'97). 

Beech  creasote  is  one  of  the  best  reme- 
dies for  habitual  constipation.  Since  em- 
ploying this  drug,  a  single  ease  has  not 
been  found  where  it  was  not  effective  or 
where  it  was  ill  borne.  It  should  be 
administered  pure,  twice  daily  after 
meals,  in  doses  of  1  to  8  drops,  beginning 
with  the  smaller  and  increasing  until 
the  desired  effect  is  secured;  the  vehicle 
is  always  water,  wine  and  water,  or  milk. 
The  result  is  probably  due  to  neutraliz- 
ing some  intestinal  toxin  which  paralyzes 
the  action  of  the  digestive  canal.  De 
Holstein  (La  Semaine  M6d.;  Lancet, 
Lond.,  Oct.  9,  '97). 

A  common  source  of  enor  is,  in  many 
cases,  the  belief  that  accumulation  of 
fceeal  matter  in  the  large  intestine  is  due 
to  imperfect  peristalsis  of  the  bowel,  and 
treatment  is  directed  to  it  specially, 
whereas  the  real  need  is  a  modification 
of  the  contents  of  the  small  intestine. 
Pfaff  (Boston  Med.  and  Surg.  Jour.,  Sept. 
9,  "97). 

Constipation   often   depends   upon   the 
loss  of  power  in  the   intestinal  muscles 
and  lack  of  secretion  of  mucus;  therefore 
treatment    should    consist    of    massage, 
proper  regulation  of  the  diet,  and  in  the 
administration  of  ipecac.     Two  and  one- 
half  drachms  of  the  aqueous  extract  of 
ipecac  is  to  be  dissolved  in  2  ounces  of 
distilled  water.     One  teaspoonful  of  this 
is  placed  in  4  ounces  of  water  and  given 
by  rectal  injection  each  morning.     Blon- 
de!   (Jour,   de   M6d.   de  Paris,   Feb.    11, 
1900). 
In  some  cases  of  special  atony  of  the 
sigmoid  flexure  of  the  colon  and  rectum 
aloin  or  extract  of  colocjTith  may  be  used 
with  advantage  instead  of  the  cascara 
sagrada  in  the  pill.    Treated  in  accord- 
ance with  the  foregoing  suggestions,  a 
large  majority  of  tlie  cases  of  ordinary 
constipation  can  be  relieved  just  as  long 
as  the  patients  will  faithfully  continue 
correct  habits  of  life. 

In  the  form  of  chronic  constipation 
due  to  a  spasmodic  contraction  of  the 
colon  treatment  should  consist  in  hydro- 


316 


CONSTIPATION.    TREATMENT. 


therapy,  diet,  and  sedatives.  Hot  com- 
presses applied  to  the  abdomen  and 
changed  every  hour  or  two  are  the  most 
important  remedial  agents.  For  the  first 
few  days  the  compresses  should  be  used 
also  at  night.  At  the  same  time  the  pa- 
tient should  receive  warm  sitz-  or  general 
baths.  Hot  douches  (28°  to  30°  C.)  di- 
rected first  against  the  abdomen,  along 
the  course  of  the  colon,  then  the  lower 
and  upper  extremities,  for  two  minutes, 
are  also  useful.  Large  injections  of  warm 
water  (37°  C.)  at  a  low  pressure  will  be 
found  beneficial.  Chamomile  or,  in  cases 
of  ulcerative  colitis,  1  pint  of  olive-oil 
may  be  advantageously  added  to  the  in- 
jections. The  latter  should  be  used  at 
first  every  night,  then  every  second  or 
fourth  day.  The  diet  should  be  free 
from  any  irritating  substances.  If  con- 
siderable intestinal  fermentation  is  pres- 
ent, meat  should  be  restricted  and  a  more 
liberal  vegetable  diet  allowed.  All  laxa- 
tives, especially  drastic  cathartics,  are 
harmful.  Romme  (La  Presse  M6d.,  No. 
18,  1900). 

The  troublesome  constipation  met 
with  in  infants  can  be  best  overcome 
generally  by  giving  them  fresh  air, 
proper  food,  and  a  rectal  enema  of  warm 
water  containing  a  little  chloride  of 
sodium  at  a  stated  time  each  day,  with- 
out any  medicine  by  the  mouth. 

When  there  is  alternately  diarrhoea 
and  constipation  in  infants  the  cause  is 
usually  due  to  an  excess  of  proteids. 
Essence  of  pepsin,  10  or  15  drops,  should 
be  given  after  nursing,  and  abdominal 
massage  is  of  value.  An  excellent  plan 
to  secure  an  action  of  the  bowel  at  a 
regular  time  is  the  insertion  of  an  oil- 
paper suppository.  The  constipation  of 
bottle-fed  infants  being  commonly  the 
result  of  a  deficiency  of  fat  in  their  food, 
the  rational  treatment  embraces  the  addi- 
tion of  cream  or  butter.  All  forms  of 
teas  should  be  strictly  jiroliibited,  and  in 
older  children  too  much  potato  should 
not  be  allowed.  Lawrence  (Med.  Record, 
July  1,  '99). 

In  artificially-fed  infants  constipation 
may  be  due  to  an  insufficiency  in  the 
fats  or  proU'ids.  The  addition  of  a  tea- 
Bpoonful    of   fresh   cream    for   each   tea- 


spoonful  of  condensed  milk  used  is  an 
eft"ective  way  of  relieving  the  constipa- 
tion following  feedings  of  condensed 
milk.  Beef-juice  is  occasionally  laxative. 
When  constipation  is  due  to  congenitiil 
stricture  of  the  anus  or  rectum,  rectal 
examination  will  reveal  the  seat  of  the 
difficulty.  When  nutrition  is  defective, 
malt-extracts  and  codliver-oil  may  be 
tried.  Enemata  shoxild  be  employed  for 
a  comparatively  short  period  only,  and 
saline  solution  is  recommended.  Black- 
ader  ("Progressive  Med.,"  vol.  i,  Mar., 
'99). 

In  infantile  constipation  excellent  re- 
sults obtained  from  administration  of 
fresh  butter.  A  half-teaspoonful  is 
given  to  children  of  from  one  to  three 
months,  with  a  spoonful  of  coffee  morn- 
ing, noon,  and  night.  Children  of  from 
five  to  twelve  months  are  fed  with  from 
1  to  3  teaspoonfuls  of  butter  at  evening, 
every  two  or  three  days,  this  being  con- 
tinued until  the  stools  are  regulated. 
When  a  normal  condition  of  the  bowels 
is  reached  the  remedy  should  be  discon- 
tinued and  resorted  to  again  if  the 
trouble  recurs.  Absolutely  fresh  butter 
should  be  employed.  The  butter  seems 
also  to  improve  nutrition.  M.  Dorfler 
(La  Presse  MCd.,  June  0,  1900). 

In  chronic  constipation  of  infants  and 
young  children  best  results  are  obtained 
by  careful  attention  to  diet,  exercise,  and 
being  much  in  the  open  air,  avoidance  of 
living  in  overheated  apartments,  massage, 
and  regularity  of  time  for  the  evacuation. 
G.    W.    Cook    (Amer.    Jour,    of   Obstet, 
Oct.,   1900). 
In  the  rare  cases  in  which  a  fair  trial 
of  enemas  and  suppositories   does  not 
succeed  a  few  drops  of  the   elixir  of 
cascara  sagrada  may  be  given  each  even- 
ing. 

Excellent  results  have  followed  the  use 
of  both  the  oil  and  glycerin  enemata  in 
the  treatment  of  constipation. 

Obstinate  constipation  and  intestinal 
diseases  may  bo  successfully  treated  by 
enemata  of  oil,  after  the  method  of 
Reiner.  Olive-oil  is  the  best,  but,  as  if 
is  rather  costly,  purified  rapc-soed  oil 
may  be  used.  The  injections  are  made 
slowly   and   earefiilly,   and   the   patients 


CONSTIPATION.    TREATMENT. 


317 


are  told  to  retain  the  oil  as  long  as  pos- 
sible, sometimes  for  several  hours.    Every 
day  an  injection  of  1  '/j  to  8  fluidounces 
of  oil  is  made,  with  the  result  that  defe- 
cation becomes  easy,  the  flatulence  dimin- 
ishes, and  in  cases  where   the  mucous 
membrane  of  the  bowel  is  more  seriously 
afTected  the  ulcers  and  chronic  catarrh 
improve.     Halk    (Ugeskrift  f.  Liiger,  p. 
601,  '90). 
Massage    is    gradually    afErming    its 
value.    In  conclusions  based  upon  study 
of  147  cases,  le  ilarmel  showed  that  (1) 
mechanical    treatment    can    be    classed 
among  those  therapeutic  agents  whose 
action  on  the  circulation,  respiration,  and 
general  nutrition  is  decidedly  energetic; 
(2)  that  it  modifies  the  abdominal  cir- 
culation and  dispels  certain  passive  con- 
gestions, especially  those  of  abdominal 
plethora;     (3)    that    it    increases    the 
muscles  in  volume  and  strength;  (4)  that 
it  is  the  best  curative  agent  for  constipa- 
tion from  muscular  paresis  or  paralysis 
not  due  to  central  nervous  disease;    (5) 
that  it  is  the  best  curative  agent  for  con- 
stipation dependent  on  hypoaBsthesia  or 
ansesthesia  due  to  local  causes;   and  (6) 
finally,  that  it  is  formally  contra-indi- 
cated when  the  "constipation  is  due  to 
acute  inilammation  or  to  tumors. 

In  cliildren  massage  removes  the  cause 
which  is  the  most  frequent:  i.e.,  atony 
of  the  muscular  coat.  It  failed  in  no 
case  in  which  it  was  thoroughly  tried. 
It  was  done  usually  about  2  p.m.,  and 
a  stool  followed  frequently  within  fifteen 
or  twenty  minutes  Sfter  the  manipula- 
tion, usually  before  evening  of  the  same 
day.  Karnitzky  (Archiv  f.  Kinderh.,  p. 
66,  '90). 

Method  of  treating  constipation  fol- 
lowed by  good  results:  The  patient  is 
made  to  lie  upon  a  bench  about  thirty- 
two  inches  wide  covered  with  a  hair  mat- 
tress, and  clad  in  light-flannel  under- 
wear, the  head  supported  by  means  of  a 
pillow,  and  the  knees  bent  up.  The 
large  intestines  only,  from  the  cteeum  to 
the  rectum,  are  massaged,  as  it  is  usually 
in  that  portion   of  the  intestinal   canal 


that  feecal  masses  are  formed  and  re- 
tained. Considerable  force  is  employed, 
the  large  intestines  being  pressed  against 
the  ilium  by  means  of  the  fingers  held 
stifi".  J.  Schreiber  (Wiener  med.  Presse, 
B.  30,  p.  808,  '95). 

The  following  process  of  massage  for 
constipation  is  far  more  efficient  than  the 
usual  process.  The  patient  is  placed  on 
his  right  side  and  the  operator  picks  up 
with  his  thumb  and  index  of  each  hand 
the  skin  and  the  subcutaneous  tissue  at 
the  level  of  the  iliac  spine.  This  makes 
the  intestine  directly  accessible  to  the 
other  fingers,  and  he  manipulates  it  with 
them,  alwaj'S  pressing  from  above  down- 
ward, and  with  the  ends  of  his  fingers, 
for  five  minutes.  Then  the  patient  is 
turned  on  the  left  side  and  the  process  is 
repeated  on  the  ca;eum,  and  the  ascend- 
ing colon,  only  in  the  opposite  direction, 
from  below  upward.  This  leaves  only 
the  small  intestine  and  the  transverse 
colon  to  be  massaged,  for  which  the  pa- 
tient is  placed  in  the  decubitus  genu- 
pectoral  position,  as  this  relaxes  the  ab- 
dominal walls  and  brings  the  intestines 
closer  into  the  hand  of  the  operator. 
Kiimmerling  (Sem.  Med.,  Dec.  5,  '95). 

For  constipation  in  infants  under  12 
months  old  that  cannot  be  relieved  by 
regulation  of  diet,  massage  is  recom- 
mended. It  should  be  given  only  in  the 
morning,  for  not  more  than  ten  minutes, 
and  the  movements  made  in  a  circle 
about  the  umbilicus;  pressure  should  be 
light  and  exerted  especially  in  the  right 
iliac  region.  For  babies  more  than  a 
year  old  the  finger-tips  are  exclusively 
employed  and  the  movements  are  con- 
fined to  the  course  of  the  large  intestine, 
from  right  lo  left.  CarriOre  (The  Prac- 
titioner; N.  C.  Med.  Jour.,  Dec.  5,  '97). 

To  perform  abdominal  massage  the 
mother  anoints  her  hand  with  sweet  oil 
or  vaselin  and  slowly  and  carefully 
kneads  the  abdominal  walls,  grasping 
the  superficial  structures  and  rubbing 
them  upon  the  underlying  ones,  follow- 
ing, respectively,  the  course  of  the  ascend- 
ing, transverse,  and  descending  colons, 
and  ending  with  a  circular  movement 
of  the  hand  around  the  umbilicus.  J 
Madison  Taylor  (Phila.  Polyclinic,  Moy 
28,  '98). 


318 


COXSTIPATIOX. 


CONVALLARIA  MAJALIS. 


Electricity  and  hypnotic  suggestion 
have  also  been  recommended.  The  first 
may  be  classed  as  an  adjuvant  to  mass- 
age of  no  mean  value  in  cases  of  intes- 
tinal atonj-,  while  the  third  may  be 
considered  as  meriting  as  yet  but  little 
confidence. 

The  theory  that  constipation  depends 
upon  an  hypertrophy  of  the  rectal 
valves  is  a  distinct  advance  and  emi- 
nently practical.  The  rectal  valves  are 
always  present,  they  are  definite  ana- 
tomical structures,  and  they  may  be- 
come pathological  and  obstructive.  In 
observing  the  cavity  of  a  rectum  with 
thickened  valves,  one  cannot  fail  to  note 
the  rigidity  and  elasticity  of  these 
bands,  which  jump  across  the  view  and 
span  two-thirds  of  the  calibre  of  the 
canal  when  relieved  by  the  withdrawal 
of  the  proctoscope.  The  lower,  or  first, 
valve  is  at  right  angles  with  the  gut 
axis,  while  the  second  and  third  are 
obliquely  placed;  so  that  it  is  evident 
that  the  first  may  be  more  obstructive. 
It  requires  the  rarest  judgment  to  de- 
termine when  the  valve  should  be  cut  or 
when  massage  will  overcome  the  ob- 
struction. The  instruments  required  for 
valvotomy  are  proctoscopes  of  graded 
lengths  for  each  valve  to  be  treated,  a 
test-hook  to  determine  the  depth  of  the 
valves,  two  tenaeula  to  secure  position 
of  the  valve,  a  valvotome,  a  curved 
needle  and  shot  compressor,  and  an 
electric  headlight.  The  patient  is  placed 
in  the  genu-pectoral  position  and  the 
proper  proctoscope  introduced.  The  se- 
lected valve  is  sprayed  with  a  1-per-cent. 
solution  of  cocaine  and  the  surface  is 
mopped  with  a  concentrated  solution  of 
Huprarcnal  extract.  The  test-hook  de- 
termines the  point  of  safety  and  depth 
at  wliifli  the  structure  may  be  divided. 
The  tenaeula  are  put  in  place  and  the 
division  effected  with  the  valvotome. 
Two  incisions  are  made  on  each  valve 
by  transfixing  and  cutting  out  through 
the  tendinous  margin.  A  suture  is 
placed  in  the  angle  of  the  gaping  wounds 
to  lessen  the  area  wliich  must  granu- 
late and  to  prevent  a  possible  perito- 
nitis.   Tlic  dangers  arc  haemorrhage  and 


peritonitis.  The  patient  is  given  a  daily 
saline  and  a  hot  enema  for  two  weeks. 
Beach  (Penna.  Med.  Jour.,  July,  1902). 
There  is  no  question  but  that  in  many 
gastro-intestinal  aflections,  and  espe- 
cially those  which  have  an  underlying 
atonic  cause,  massage  has  gi-eat  ef- 
ficiency. It  should,  nevertheless,  be 
relegated  to  a  second  position  by  the 
clinician,  but  should  not  be  entirely  for- 
gotten. With  reference  to  the  tech- 
nique, there  are  many  things  to  be  con- 
sidered, but  in  general  that  of  Hoffa  is 
to  be  preferred.  The  writer  reports  a 
series  of  cases  in  which  intestinal  mas- 
sage has  proven  of  service.  H.  Koett- 
leitz  (Ann.  de  la  Polycl.  de  Paris,  vol. 
xiv,  p.  49,  1903). 
Nathan  S.  Davis  (Chicago)  and 
Centeal  Staff  (Philadelphia). 

CONTINUED  FEVEK.    See  Malahia. 

CONTUSION.     See  Wounds. 

CONVALLAKIA      MAJALIS. —  The 

lily  of  the  valley,  a  native  alike  of  Eu- 
rope and  North  America,  has  long  been 
held  in  high  repute  in  Eussia,  Germany, 
and  Scandinavia  as  a  plant  possessed  of 
great  therapeutic  virtues,  rivaling  those 
of  purple  fox-glove.  It  is  a  perennial; 
has  a  creeping,  much-branched  rhizome 
of  about  the  thickness  of  a  quill;  two 
or  three  elliptical  and  smooth  radicle 
leaves;  a  one-sided  racime  of  light,  ten 
or  twelve  nodding,  bell-shaped,  six- 
lobed,  white  flowers;  very  fragant,  but 
of  acrid  and  bitter  taste.  As  found  in 
shops,  it  appears  in  cylindrical,  wrinkled, 
whitish  pieces  marked  by  circular  scars; 
at  the  annulate  point,  eight  or  ten  root- 
lets. Both  the  rhizome  and  the  roots  are 
medicinal. 

The  active  principles  are  two  glu- 
cosides,  denominated,  respectively,  con- 
vallamarin  and  convallarin:  the  first  a 
pale-whitish-ljrown  amorphous  powder, 
soluble  in  both  alcohol  and  water;  the 
second  a  brownish-white  powder  soluble 
in  alcohol  only. 


CONVALLARIA  MAJALIS. 


319 


Preparations  and  Doses. — Convallaria 
extract,  solid,  5  to  15  grains. 

Convallaria  exiract,  fluid,  2  to  20 
minims. 

Convallaria  infusion  (10  grains  of 
flowers  to  6  ounces  of  water),  2  to  8 
drachms. 

Convallamarin,  V*  to  2  grains. 

Convallarin,  2  to  4  grains. 

Physiological  Action.  —  Moderate 
doses  slow  and  strengthen  the  heart's 
contractions;  larger  doses  accelerate  the 
heart  and  induce  irregularity;  toxic 
doses  cause  progressive  paralysis,  mus- 
cular tremors,  complete  loss  of  reflex 
action,  and  death  when  the  heart  is 
arrested  in  systole.  Doses  that  slow  the 
heart  heighten  arterial  tension;  it  prob- 
ably also  acts  directly  upon  the  blood- 
vessels. Like  digitalis,  it  is  a  most  ef- 
ficient diuretic  when  given  in  the  form 
of  an  infusion,  but  is  apt  to  be  uncer- 
tain in  its  efEects  upon  the  kidneys  when 
exhibited  in  any  other  form;  it  is  also 
emetic  and  cathartic.  While  the  effect 
upon  the  circulation  is  very  like  that  of 
fox-glove,  it  is  a  more  uncertain  remedy, 
and  likewise  a  less  powerful  one. 

While  the  tonic  action  on  the  heart 
is  about  the  same  with  both  convalla- 
marin and  lily  of  the  valley,  the  di- 
uretic properties  are  in  great  part  to 
he  attributed  to  the  fresh  convallarin. 
Unfortunately  the  drug  varies  consider- 
ably in  strength,  depending  upon  the 
quality  of  material  employed,  the  use 
of  heat  in  the  manufacture  of  the  ex- 
tract, and  other  unknown  factors. 
Hence  a  constant  pharmaceutical  prep- 
aration in  the  form  of  the  juice  of  the 
fresh  plant  is  necessary.  It  contains 
2.25  grammes  of  convallamarin  and  1.2 
grammes  of  convallamarin  per  kilo- 
gramme; possesses  all  the  physiological 
properties  of  the  plant  itself,  and  may 
be  employed  in  doses  of  from  5  to  1.) 
centigi-ammcs,  gradually  increasing  by 
5  centigrammes.  D.  Laigre  (Rev.  de 
Ther.  Jled.  Chir.,  Nov.  1.5,  1903). 


Convallamarin  reduces  the  pulse-rate, 
markedly  increases  the  flow  of  urine,  and 
is  "cumulative"'  in  exactly  the  same  way 
that  digitalis  is:  i.e.,  when  exhibited  in 
a  way  that  fails  to  provide  for  or  secure 
proper  elimination;  because  of  this 
"cumulative"  bugbear,  it  has  been  sug- 
gested that  more  than  one  dose  during 
twenty-four  hours  should  not  be  admin- 
istered to  the  same  patient;  but  this  pre- 
caution is  entirely  superfluous  if  the 
drug  is  exhibited  intelligently  and  its 
effects  carefully  watched.  This  gluco- 
side,  however,  is  in  every  way  inferior  to 
preparations  of  the  entire  drug,  and  all 
the  latter  are  inferior  to  the  infusion. 

Convallarin  is  both  emetic  and  purga- 
tive. 

Therapeutics.  —  Circulatoet  Dis- 
eases.— Opinions  differ  greatly  as  to  the 
value  of  the  drug.     By  a  score  of  ob- 
servers it  has  been  extravagantly  lauded 
and  by  as  many  more  condemned  with 
proportionate  severity.    It  should  be  re- 
membered, however,  that  the  strength 
of  the  different  preparations  of  different 
manufacturers  vary.     Again,  some  em- 
ploy the  petals  of  the  flowers  only;  some 
the  rhizome;    some  the  root;    some  the 
entire'  plant.    Justice  demands  a  stand- 
ard be  set,  and  the  plant  studied  more 
carefully  from  such  definite  stand-point. 
In   dropsy  of  renal   or  hepatic  origin 
convallaria  majahs  in  an  infusion  of  4 
grammes  of  the  plant  to  ISO  grammes  of 
water,   a   tablespoonful   every   2    hours, 
changing  later  to  a   1   to    12   alcoholic 
tincture,   of  which  45   to   80   drops   are 
taken  during  the  day,  is  valuable.     It 
also  favorably  influences  the  diuresis  in 
hepatic  cirrhosis.    .Taliowski  (Sem.  Mfd., 
Mar.  in,  '98). 

CONVUXSIONS,    INFANTILE.       Se* 

Spasms    and   Coxvulsioxs    ix    Chil- 
DRE^^ 

COPAIBA.  —  "Balsam"  copaiba,  or 
copaiva,  is  the  common  designation  of 


320 


COPAIBA.     PKEPARATIOXS.     PHYSIOLOGICAL  ACTION. 


this  drug,  but  is  exceedingly  inappro- 
priate, since  it  contains  neither  of  the 
requisites  of  a  true  balsam,  viz.:  benzoic 
or  cinnamic  acid.  It  is,  in  fact,  an  oleo- 
resin  supposed  to  be  derived  from  Co- 
paifera  Langsdorffii^  but  as  frequently, 
perhaps,  had  from  other,  but  relative, 
sources,  such  as  C.  officinalis,  C.  multi- 
juga,  C.  Guianensis,  C.  coriacea,  C. 
nitida,  C.  Martii,  C.  cordifolia,  C.  Jus- 
sieui,  C.  Jacquini,  etc.,  all  indigenous  to 
South  America  or  the  West  Indies  and 
the  valleys  of  the  Madeira,  Orinoco,  and 
Amazon;  the  best  comes  from  Belem 
(Para),  as  its  average  of  volatile  oil  is 
larger,  ranging  from  60  to  90  per  cent., 
while  its  most  important  rival,  Maran- 
ham  copaiba,  at  most  never  yields  more 
than  80  per  cent,  and  seldom  more  than 
40,  which  last  equals  that  of  Maracaibo. 

Para  copaiba  is  pale  colored  and 
limpid,  Maranham  and  Eio  Janeiro  of 
an  olive-oil  consistence,  and  all  three 
form  clear  mixtures  with  one-third  to 
one-half  their  volume  of  ammonia-water, 
but  milky  if  more  alkali  or  fixed  oil  is 
present.  Maracaibo — and  all  dark  co- 
paibas obtain  this  name  commercially — 
is  thick,  dark  yellow  or  reddish  brown, 
turbid,  and  solidifies  with  magnesia. 
Besides  the  volatile  oil  is  contained  a 
resin  and  bitter  principle  known  as  co- 
paivic  acid:  oxycopaivic  acid  from  the 
Para  form,  metacopaivic  acid  from  that 
dubbed  Maracaibo.  The  odor  is  peculiar 
and  characteristic;  the  taste,  hot,  nause- 
ous, and  bitter;  is  freely  soluble  in  ether, 
alcohol,  fixed  and  volatile  oils,  but  not 
at  all  in  water  unless  it  is  previously 
rendered  alkaline. 

Copaiba-oil  is  obtained  by  distillation, 
and  in  this  the  therapeutic  virtues  of  the 
oleoresin  chiefly  reside.  It  is  a  pale- 
yellowish  liquid;  aromatic;  bitter,  pun- 
gent taate  and  characteristic  odor;   that 


from  Maracaibo  copaiba  has  a  dark-blue 
tinge. 

Unfortunately  copaiba  is  rarely  ob- 
tained in  its  purity;  that  in  the  shops  is 
usually  adulterated  with  turpentine,  gur- 
jun  balsam,  or  castor-  or  linseed-  oils. 

Preparations  and  Doses.  —  Copaiba 
(oleoresin),  5  to  15  grains  or  minims. 

Copaiba  injection,  urethral  (copaiba, 
10;  sodium  bicarbonate,  5;  tincture  of 
opium,  1;  distilled  water,  to  make  768 
parts),  ad  libitum. 

Copaiba  mass  (solidified  copaiba,  10  to 
60  grains)  speedily  becomes  insoluble. 

Copaiba  mixture  (copaiba,  6;  liquor 
potassa,  4;  gum-arabic  mucilage,  8; 
spirit  of  nitrous  ether,  24;  cinnamon- 
water,  64),  2  to  5  drachms  and  more. 

Copaiba  mixture,  Chopart-Wolff's  (co- 
paiba, 8;  syrup  of  Tolu,  8;  alcohol,  8; 
spirit  of  nitrous  ether,  1),  2  to  5 
drachms. 

Copaiba-oil  3  to  15  minims. 

It  may  here  be  noted  the  custom  of 
making  pills  of  copaiba  by  the  aid  of 
magnesia  carbonate,  and  by  mixing  with 
wax,  is  pernicious;  neither  pill-mass  is 
freely  soluble,  and  absorption  of  the 
remedy  is  restricted  and  in  a  measure 
inhibited. 

Physiological  Action.  —  Applied  lo- 
cally both  the  oil  and  the  oleoresin  ap- 
pear to  be  slightly  stimulant.  Internally 
in  medicinal  doses  they  stimulate  the 
kidneys  to  freer  action,  without,  how- 
ever, materially  affecting  or  modifying 
the  solid  constituents  of  the  urine. 

Copaiba  stimulates  mucous  membrane 
generally,  more  especially  of  the  genito- 
urinary and  respiratory  tracts;  is  some- 
what feebly  astringent,  and  decidedly 
antiseptic.  Its  prolonged  use  is  not  un- 
attended with  danger  and  is  apt  to  in- 
duce considerable  gastro-intestinal  irri- 
tation, gastric  oppression,  anorexia, 
nausea,    vomiting,    purging,    and    con- 


COPAIBA.     POISONING.     TREATMENT.     THERAPEUTICS. 


321 


gestion  of  the  upper  air-passages,  of  the 
conjunctiva,  irritation  of  bladder  and 
kidneys,  perhaps  to  the  setting  up  of  a 
nephritis  or  cystitis,  or  both.  Unpleas- 
ant skin  eruptions  accompanied  by  in- 
ordinate itching  and  tingling  are  com- 
mon sequels  to  its  use;  usually  these 
consist  of  bright-red  papules  closely  re- 
sembling the  efflorescence  of  measles,  but 
sometimes  scarlatina-like.  They  begin 
on  the  hands,  gradually  spreading  to 
arms,  trunk,  and  lower  extremities. 

The  drug  is  very  rapidly  absorbed 
into  the  circulation,  and  is  eliminated 
chiefly  by  the  kidneys  and  respiratory 
tract,  and  to  some  extent  by  the  skin. 

Copaiba  Poisoning. — Copaiba  is  cer- 
tainly toxic,  though  there  is  no  definite 
evidence  of  its  ever  having  been  a  direct 
cause  of  death.  Indirectly  it  is  accused 
of  giving  rise  to  severe  manifestations 
resembling  rheumatic  seizures  and  to 
renal  dropsy.  The  toxic  symptoms  are 
those  accruing  to  large  or  long-continued 
doses,  greatly  exaggerated,  along  with 
weakening  of  arms,  of  muscles,  of  face; 
paralysis;  desquamative  and  pustular 
eruptions,  and,  more  rarely,  tetanoid 
seiziires. 

The  drug  has  a  manifest  effect  upon 
the  skin  and  is  likewise  an  epithelial 
irritant;  but  its  action  appears  to  be 
greatly  influenced  by  individual  suscep- 
tibility. Assuming  that  symptomatic 
dermatitis  ensues  as  part  of  a  general 
excretory  action,  practical  conclusion 
must  be  that  all  drugs  which  produce 
eruptions  should  be  prescribed  with  cau- 
tion lest  they  injure  other  organs.  Walsh 
(Med.  Press  and  Circ,  No.  3058,  '97). 

Treatment  of  Copaiba  Poisoning. — 
The  toxic  symptoms  are  rarely  such  as 
to  require  measures  other  than  with- 
drawal of  the  drug  and  the  promoting 
of  excretion  by  all  the  emunctories. 
Diuretics  and  cathartics  may  be  em- 
ployed, and  cannabis  Indica  or  opium 
used  to  allay  pain. 

2- 


Therapeutics. — As   a   whole,    copaiba 
promises  little  therapeutically  that  can- 
not be  more   palatably  and   easily   ob- 
tained through  the  use  of  oleoresin  of 
cubeb,    oil    of    turpentine,    and    other 
agents  of  this  class.    If  prescribed,  it  is 
best  given  in  capsules,  preferably  dis- 
solved in  some  bland  oil.    It  frequently 
appears  in  capsular  form  in  conjunction 
with  oil  of  sandal-wood,  or  eucalyptus, 
or  cubeb.    In  mixtures  its  nauseousness 
may,  in  part,  be  overcome  by  the  use  of 
spirit  of  chloroform,  chloroform-water, 
and  aromatics.    The  oil  is,  in  every  way, 
a  preferable  preparation  to  the  oleoresin, 
being  a  more  constant  and  definite  agent. 
Copaiba,  balsam  of  copaiba,  or,  more 
correctly,  oleoresin  of  copaiba,  contains 
two   acid   resins,   the   principal   one   be- 
ing copaibic  acid,  C^jHj.O;,  a  crystalliz- 
able  substance.     This  forms  with  bases 
combinations    yet    little    known,    which 
are  soluble  in  alcohol  and  ether,  but  in- 
soluble in  water.     At  ordinary  temper- 
atures potassium  copaibate  is  a  thick, 
clear,  reddish-brown  liquid;  its  taste  is 
acrid  and  peppery;   its  odor  similar  to 
tliat  of  copaiba,  and  its  reaction  alka- 
line; it  is  soluble  in  alcohol,  ether,  or 
chlorofonn;    with    water    it    yields    an 
opalescent  mixture  which  soon  becomes 
milky    from    decomposition    of    the    co- 
paibate.    According  to  the  author,  the 
therapeutic  properties  of  potassium  co- 
paibate are   analogous   to   those  of  co- 
paiba.    The    dose    is    from    50    to    150 
grains   a   day,   best   taken   in    lO-grain 
capsules.    The  average  man  will  toler- 
ate two  capsules  thrice  daily;   the  ro- 
bust,    with     strong     digestive     powers, 
twelve    daily,    while    the    weakly    and 
tliosc  easily  purged  do  not  bear  more 
than  four  a  day.     The  untoward  cfTects 
of  the  copaibate  are  similar  to  those  of 
copaiba,  but  not  so  severe  or  frequent; 
after-taste,  cructntions.  and  gastric  op- 
prc^^sion  are  but   seldom   produced,  and 
lumbar  pains  do  not  appear  or  are  so 
slight  as  to  escape  comment;  excessive 
doses    produce   catharsis.    It    provokes 
skin  eruptions  just  as  copaiba  does  in 
susceptible    individuals,    but    this    need 
21 


322 


COPAIBA. 


not  of  necessity  cause  discontinuance 
of  the  drug.  The  writer  has  cured  with 
it  chronic  eczema  of  the  hands  and  legs, 
and  acne  rosacea  and  acne  vulgaris 
have  been  gi-eatly  improved  by  applying 
the  drug  undiluted  and  removing  it  by 
washing  with  water  as  soon  as  burning 
begins  to  be  felt.  Two  or  three  drops 
to  a  fluidounce  of  water  offers  a  solu- 
tion which  is  an  agreeable  cleansing  and 
palliative  spray  in  catarrh  of  the  nose 
and  throat.  L.  Kolipinski  (Medical 
Xews,  Sept.  12,  1903). 

GoxoERHCEA. — It  is  in  this  malady 
that  copaiba  has  found  chief  employ- 
ment, solely  because  of  its  antiseptic 
properties  and  afSnity  for  mucous  tis- 
sues; and  for  all  that  many  practitioners 
in  the  management  of  this  malady  still 
rely  on  this  drug,  alone  or  in  conjunction 
with  other  diuretics  or  drugs  of  the  same 
class.  It  is  much  overrated,  and  its  real 
merits  are  nowise  compensatory  for  the 
nausea  and  disagreeable  sequels  that  fol- 
low in  its  train.  Again,  the  uncertainty 
attending  the  character  of  the  drug  per 
se  is  such  that  oleoresin  cubeb,  which  is 
equally  effective,  is  a  more  desirable 
remedy,  although  perhaps  less  diuretic, 
but  even  in  this  respect  it  may  be  ren- 
dered superior  to  copaiba  by  the  addi- 
tion of  an  extremely  minute  quantity 
of  cantharides.  Copaiba  is  also  used  as 
a  urethral  injection. 

LEUCOREHffiA. — The  internal  admin- 
istration of  copaiba  often  seems  bene- 
ficial in  the  fluxes  of  females,  and  also 
the  pudendal  eruptions  that  accrue  to  or 
are  sequels  of  these  discharges. 

Pulmonary  Diseases. — These,  when 
attended  by  excessive  secretion,  are  often 
benefited  by  this  drug;  it  is  especially 
available  in  restraining  and  modifying 
bronchial  secretion,  more  particularly  in 
the  aged;  but  it  is  inadmissible  when 
there  is  much  vascular  irritability  or 
fever. 

Hepatic  Diseases. — la  cirrhosis  of 


the  liver  copaiba,  especially  when  com- 
bined with  cardiac  disorders,  has  been 
found  of  considerable  value. 

GONOEKHCEAL    RHEUMATISM. It    lias 

been  claimed  that  this  drug  is  eminently 
serviceable  in  the  management  of  gonor- 
rhoeal  rheumatism,  but  that  it  must  also 
be  given  in  very  small  doses  and  per- 
sisted in  for  some  length  of  time;  also 
that  colchicum  may  be  advantageously 
connected  therewith.  But  the  rationale 
of  the  foregoing  has  never  been  eluci- 
dated. 

Skin  Diseases. — Externally  the  drug 
has  been  recommended  in  the  treatment 
of  chronic  skin  diseases,  notably  psori- 
asis, lepra,  lupus,  etc.,  but  its  value 
therein  is  decidedly  problematical,  ex- 
cept for  its  antiseptic  and  stimulating 
effects.  Also  it  has  recently  been  re- 
vised as  a  dressing  for  chronic  and  in- 
dolent ulcers,  though  its  value  here  is 
no  greater  than — if  as  good  as — that  of 
many  balsamic  resins. 

COPPEE.— Copper  is  a  metal  that 
in  its  pure  state  appears  to  exercise 
little  or  no  effect  upon  the  human 
economy,  but  acts  as  an  irritant  poi- 
son in  combination  with  acids,  no 
matter  whether  the  combination  is 
effected  within  or  without  the  body. 
Food  cooked  in  copper  utensils  that  are 
not  kept  constantly  polished  in  their  in- 
terior, by  dissolving  a  portion  of  the 
metal,  and  converting  it  into  salts,  proves 
highly  toxic;  like  transformations  oc- 
cur through  the  secretions  by  inhaling 
or  otherwise  absorbing  fine  particles,  as, 
for  instance,  in  coppersmith's  and  brass- 
maker's  disease.  In  medicine  its  chief 
value  ia  as  a  base  for  the  formation  of 
salts.  It  forms  two  oxides,  red  and 
black,  known,  respectively,  as  cuprous 
and  cupric,  the  latter  alone  being  em- 
ployed therapeutically. 


COPPER.  PREPARATIONS  AND  DOSES. 


323 


Preparations  and  Doses. — Copper  ace- 
tate, normal,  Vs  to  V2  grain. 

Copper  aliiminate,  mild  caustic  only. 

Copper  and  ammonium  sulphate  (am- 
moniated  copper),  V^  to  3  grains. 

Copper  arsenate,  V2S  to  Va  grain.  See 
Arsenic. 

Copper  arsenite,  V121  to  V2  grain.  See 
Arsenic. 

Copper  benzoate,  external  use  only. 

Copper  bichromate,  caustic  only. 

Copper  bromide,  Viso  to  Vs  grain. 

Copper  carbonate,  1  to  6  grains. 

Copper  chloride,  Vio  to  Vs  grain. 

Copper  diacetate  (subacetate),  external 
use  only. 

Copper  iodide,  Vsoo  to  Vioo  grain. 

Copper  nitrate,  V12  to  Ve  grain. 

Copper  oleate,  external  only. 

Copper  oxide  (black),  V*  to  1  Vs 
grains. 

Copper  penta  sulphate,  in  technical 
use  only. 

Copper  phosphate,  Vs  to  ^/a  grain. 

Copper  salicylate,  external  use  only. 

Cupratin,  1  to  4  grains. 

Cuprein.    See  Cinchona. 

Metallic  Copper. — Though  pure  metal- 
lic copper  is  generally  held  to  be  inert 
per  se,  it  is  sometimes  employed  in  chole- 
raic maladies,  colic,  and  seizures  of  like 
character.  The  virtues,  whatever  may 
exist,  most  assuredly  must  arise  from  the 
chemical  change  that  takes  place  within 
the  body;  probably  a  chloride  is  formed 
there. 

Copper  Acetate. — Normal  copper  ace- 
tate is  by  no  means  the  basic  acetate,  and 
the  latter  finds  only  technical  applica- 
tion. The  former,  known  also  as  verde- 
gris,  and  crystallized  verdegris,  if  pure, 
is  obtained  in  conglomerations  of  large, 
dark-green  crj'stals;  has  a  metallic  taste 
and  acetous  odor;  melts  at  328°  F.;  is 
decomposed  by  water;   soluble  in  water 


and  alcohol.    It  requires  to  be  kept  well 
stoppered. 

Ammoniated  copper,  or  more  properly 
copper  and  ammonium  sulphate,  appears 
in.  the  form  of  a  dark-blue,  crystalline 
powder,  freely  soluble  in  water,  and  is 
regarded  as  an  astringent  and  antispas- 
modic remedy. 

Copper  arsenate  varies  in  its  form  and 
composition;  it  should  appear  as  a  blue 
powder,  and  is  freely  soluble  only  in 
acids;  it  is  little  employed,  but  at  one 
time  held  high  rank  as  an  alterative  and 
antisyphilitic. 

Copper  arsenite  (ortho-arsenite  of  cop- 
per, or  Scheele's  green)  is  a  pale-  or  yel- 
lowish- green,  amorphous  powder,  soluble 
in  alkaline  solutions,  slightly  soluble  in 
water,  and  claimed  to  be  antispasmodic 
and  also  an  intestinal  antiseptic.  See 
Arsenic. 

Benzoate  of  copper  is  made  up  of  light- 
blue,  crystalline  plates  or  needles,  though 
it  is  sometimes  obtained  in  powder.  It 
finds  no  employment  at  all  by  way  of 
the  stomach. 

Copper  bichromate  is  a  deliquescent, 
brown,  crystalline  salt  that  requires  to  be 
always  Kept  in  a  closely-stoppered  bot- 
tle; it  is  soluble  in  water  and  in  alcohol, 
and  of  but  little  use  at  all  except  for  its 
caustic  action. 

Bromide  of  copper,  like  every  other 
bromine  derivative,  has  been  tried  in 
lieu  of  other  bromides,  especially  in 
chorea  and  epilepsy,  but  was  speedily 
found  to  be  a  remedy  for  evil  rather  than 
good,  and  highly  irritating  to  the  stom- 
ach. It  is  a  grayish-black,  crystalline 
powder  resembling  graphite,  but  soluble 
in  water. 

Copper  Carbonate. — There  are  two 
forms  of  copper  carbonate,  viz.:  the  blue 
(sesquicupric  carbonate),  which  is  used 
only  as  a  pigment;  and  the  green  car- 
bonate (dicupric  carbonate,  or  artificial 


324 


COPPER.     PREPARATIONS  AND  DOSES. 


carbonate),  which  is  obtained  in  pow- 
dered form  and  is  soluble  in  acids  only. 
It  has  been  chiefly  employed  as  an  anti- 
dote in  phosphorus  poisoning. 

CMoriJe  of  copper  has  been  employed 
on  a  few  occasions  as  a  remedy  and  as  a 
substitute  for  the  sulphate,  but  it  pos- 
sesses no  advantages  over  the  latter,  and 
is  even  more  caustic ;  it  finds  its  principal 
use  in  the  laboratory  of  the  chemist. 

Nitrate  of  copper  (normal)  appears  as 
deep-blue,  prismatic,  deliquescent  crys- 
tals, obtained  by  dissolving  the  metal  in 
nitric  acid,  evaporating,  and  cooling  at 
a  temperature  not  lower  than  70°  F.  It 
is  soluble  in  water  and  alcohol,  and  by 
the  late  Dr.  Fleming  was  held  to  be 
superior  to  all  other  caustics  in  lupus, 
malignant  ulcerations,  and  the  small  ex- 
cavated semiphagedenic  ulcers  which  oc- 
cur on  the  genital  organs  of  both  males 
and  females.  It  is  very  deliquescent,  and 
can  only  be  applied  in  a  liquid  state,  the 
surrounding  parts  being  well  protected 
by  oil.  It  differs  from  the  sulphate  in 
exciting  a  stronger,  healthy  or  alterative 
action  in  the  tissues  around  the  ulcer 
after  its  destruction.  A  capital  detergent 
lotion  is  had  by  dissolving  2  minims  of 
the  liquid  nitrate  of  copper  in  an  ounce 
of  water.  It  has  been  administered  in- 
ternally as  an  antisyphilitic,  but  without 
sufficient  success  to  encourage  its  further 
use. 

Oleate  of  copper,  so  called,  is  really  an 
oleopalmitate,  and  is  best  prepared  by 
the  double  decomposition  of  a  hot  solu- 
tion of  cupric  sulphate  (3  to  8  of  water) 
added  to  a  hot  solution  of  Castile  soap 
(8  to  32)  and  washing  and  drying  the 
precipitate.  On  cooling  it  forms  in  solid, 
dark-green  masses  that  may  be  subse- 
quently pulverized.  It  finds  chief  em- 
ployment in  plasters  for  warts  and  corns. 
An  ointment  is  sometimes  made  by  add- 
ing 1  part  of  cupric  oleate  to  4  parts  of 


an  ointment-base,  preferably  one  made 
with  2  parts  of  vaselin  and  1  part  of  par- 
affin. 

Blach  oxide  of  copper — there  is  a  red 
oxide  also,  but  it  only  finds  technical 
employment — or  cupric  monoxide,  is  a 
brownish-black,  amorphous  powder  that 
has  been  employed  as  a  ttenicide  and  re- 
solvent. 

Phosphate  of  copper  is  a  bluish-green 
powder,  at  one  time  heralded  as  a  panacea 
for  tuberculosis. 

Copper  salicylate  appears  in  the  form 
of  bluish-green  microscopical  needles 
that  are  soluble  in  water,  and  has  found 
its  chief  use  as  an  antiseptic  application. 

Copper  sulphate,  sometimes  termed 
blue  vitriol,  occurs  as  large,  deep-blue, 
efilorescent  crystals  of  strong,  metallic, 
styptic  taste.  It  is  soluble  in  2.6  parts  of 
water  at  59°  F.,  in  0.5°  F.  of  boiling 
water,  and  3.5  parts  of  glycerin;  insol- 
uble in  alcohol:  decomposed  by  alkaline 
carbonates,  borax,  lead  acetate,  silver  ni- 
trate, mercuric  bichloride,  calcium  chlo- 
ride, and  precipitated  by  all  astringent 
vegetable  infusions.  It  is  mildly  eseha- 
rotic,  irritant,  and  in  weak  solutions 
stimulant  and  astringent;  in  large  doses 
emetic,  but  undesirable,  and  oftentimes 
dangerous  as  such,  except  in  cases  of 
phosphorus  poisoning,  when  it  proves 
of  special  value  because  of  the  chemical 
changes  induced. 

Copper  sulphide,  cupric  and  copper 
sulphide  cuprous,  have  been  employed  as 
external  applications  in  various  degrees 
of  dilution,  but  with  no  very  satisfactory 
results:  they  are  of  more  value  to  the 
technical  chemist  than  to  the  physician. 

Cupraiin  is  a  copper  albuminoid  prep- 
aration analogous  to  ferratin. 

Copper  ointmsnt  is  had  in  two  forms, 
one  of  which  is  also  termed  a  liniment. 
Thus,  copper  ointment  proper — which 
obtains    the    Bynonyms    of    unguentvm 


COPPER.    PHYSIOLOGICAL  ACTION.    POISONING. 


325 


wruginis,  Egyptian  ointment,  and  verdi- 
gris ointment — is  made  by  incorporating 
30  grains  of  the  finely-powdered  diace- 
tate  ("prepared  subacetate")  salt  with 
7  Ya  drachms  of  ointment-base,  prefer- 
ably that  made  with  white  wax.  It  is  a 
mild  stimulant  and  escharotic. 

The  copper  liniment,  also  known  as 
linimentum  ceruginis,  oxymel  cupri  sub- 
acetas,  unguentum  JEgijpiiacum, is  a  stim- 
ulant, detergent,  and  slightly-escharotic 
preparation,  made  by  dissolving  1  ounce 
of  cupric  diacetate  in  7  ounces  of  dis- 
tilled vinegar,  and  then  adding  14  ounces 
of  honey. 

Physiological  Action. — All  the  copper 
salts  are  more  or  less  astringent  both  in 
substance  and  solution,  the  difference  for 
the  most  part  being  those  of  degree; 
applied  to  abraded  surfaces,  they  are 
caustic.  Internally  they  are  gastro-intes- 
tinal  irritants.  Though  often  tonic  in 
minute  doses,  they  are  not  generally  well 
borne  for  any  length  of  time,  but,  like 
the  ingestion  of  single  large  doses,  pro- 
voke nausea,  perhaps  vomiting,  and  sali- 
vation and  purging  of  blood  and  mucus. 
They  are  also  depressant  to  the  nervous 
system;  to  the  respiratory  action,  which 
is  likewise  accelerated;  and  to  the  heart's 
action,  causing  a  small,  weak,  rapid  pulse. 
Minute  doses  augment  all  the  secretions. 
All  are  but  slowly  absorbed  and  even 
slower  eliminated,  this  process  taking 
place  by  way  of  the  prima  vice,  the  sali- 
vary glands,  the  kidneys,  and  liver,  and 
there  is  always  a  tendency  to  accumulate 
in  the  latter  organ. 

People  who  work  in  the  copper  mines 
are  liable  to  a  peculiar  greenish  colora- 
tion of  the  hair,  regardless  of  its  original 
hue.  The  beard  and  moustache  are  first 
afTected,  then  the  hair  of  the  scalp;  and 
the  metal  can  be  demonstrated  in  the 
hirsute  growth  chemically,  and  under  the 


microscope  the  color  is  seen  to  be  uni- 
formly distributed. 

It  will  be  observed  that  the  physiolog- 
ical action  of  copper  salts  within  the 
economy  is  largely  speculative;  they  are 
not  employed  therapeutically  sufficiently 
often  to  excite  special  studies  in  this  di- 
rection, though  such  are  greatly  to  be 
desired. 

Poisoning  by  Copper  Salts. — Here  the 
arsenical  copper  salts  must  be  excluded, 
as  they  partake  of  the  nature  of  arsenic 
(see  Arsenic).  As  regards  the  others, 
this  action  is  pretty  nearly  coincident 
and  uniform,  and  chiefly  exaggerations 
of  their  effects  in  large  medicinal  doses. 
The  symptoms  are:  vomiting,  pain  in 
bowels,  cramps  in  lower  extremities, 
strong  coppery  taste  in  mouth,  diarrhoea, 
convulsions,  paralysis,  insensibility,  and 
death;  marks  of  inflammation  in  the 
stomach  and  intestines  are  often  noticed 
at  the  post-mortem,  and,  where  the  case 
has  been  protracted,  there  is  often  a  green 
tinge  of  the  lining  membranes  of  the 
prima  vice  and  a  jaundiced  appearance  of 
the  skin. 

Acute  poisoning  results  from  the  in- 
halation of  copper  fumes,  eating  fruits 
cooked  in  copper  utensils^  or  from  an 
overdose  of  a  copper  salt,  ^^'llen  in- 
haled, the  first  symptoms  are  those  of 
bronchial  catarrh  and  irritation.  In- 
ternally administered  the  symptoms  do 
not  usually  appear  at  once;  but  after  an 
hour's  interval  there  are  manifest  a 
strong  metallic  taste  in  the  mouth, 
burning  and  constriction  of  the  pharynx 
and  fauces,  salivation  and  vomiting  of 
greenish  matter,  and  purging,  the  pas- 
sages after  awhile  containing  mucua 
streaked  with  blood.  There  are  present, 
also,  burning  in  the  epigastrium  and 
griping,  colicky  pains.  A  characteristic 
symptom  is  a  green  line  on  tlie  gums. 
Sometimes  jaundice  may  be  present; 
and  headache,  convulsions,  suppression 
of  iirine,  cardiac  depression,  and  hurried 
respiration  arc  among  the  more  grave 


326 


COPPER.     POISOXING.     TEEATilEXT. 


symptoms.  Butler  ("Text-book  of  Mat. 
Med.,  Pharm.,  and  Therap.,"  "96). 

In  four  cases,  all  with  a  previous  his- 
tory of  good  health,  there  was  a  sudden 
onset  of  gastric  disturbance  more  or  less 
severe,  speedily  followed  by  pains  ac- 
companied by  dysphagia,  cramps,  head- 
ache, and  vertigo.  Vomiting  terminated 
the  severity  of  the  symptoms.  Gentile 
(La  Riforma  Med.,  No.  42,  '90). 

Case  of  copper  poisoning  apparently 
due  to  the  handling  of  vines  that  had 
been  treated  on  three  or  four  occasions 
with  applications  of  a  solution  contain- 
ing copper.     Danet  (Le  Bull.  Mfid.,  '97). 

It  is  only  in  acute  conditions  that 
poisoning  by  copper  salts  can  occur,  and 
then  it  is  not  a  question  of  true  poison- 
ing, but  of  a  gastro-intestinal  irritation 
analogous  to  that  which  is  produced  by 
a  common  caustic.  Very  exceptionally 
are  serious  symptoms  of  poisoning  ob- 
served, as  the  organism  has  the  greatest 
tepdency  to  free  itself  from  substances 
which  possess  emetic  properties.  Galippe 
(Nouv.  RemCd.,  July  8,  '97). 

Method  of  testing  copper  salts  for 
coloring  green  pease:  Green  pease  were 
boiled  in  a  solution  of  copper  sulphate 
until  they  had  absorbed  all  the  copper 
in  the  solution.  Then  fresh  pease  were 
boiled  in  water  for  the  same  length  of 
time.  Next  a  few  of  the  colored  pease 
and  a  few  of  the  uneolored  were  boiled 
for  three  minutes  in  a  10-per-cent.  solu- 
tion of  sulphuric  acid.  Kach  sample  was 
then  poured  out  on  a  white  saucer.  The 
pulp  of  the  colored  pease  as  well  as  their 
skins  always  retained  the  green  color 
after  this  test  in  a  degree  which  was 
proportionate  to  the  quantity  of  copper 
present,  while  the  pease  that  had  not 
been  colored  turned  a  brownish  or  gray- 
ish hlack.  By  this  method  so  small  a 
quantity  as  0.025  gramme  of  copper  in  a 
kilogramme  of  pease  was  detected.  A. 
V.  Nikitine  (Vratch,  Mar.  11,  1000). 

Symptoms  of  greatest  value  in  the 
recognition  of  copper  poisoning  are  (1) 
dyspcpgia,  v.hicli  is  the  earliest  of  all 
nymptomB;  (2)  anoemia,  which  comes 
on  before  emaciation,  loss  of  strength, 
and  the  ratlier  characteristic  painful 
facial   expression;     (.3)    nervousness  and 


irritability.    H.  A.  Kurth  (Med.  Record, 
Nov.  10,  1900). 

Treatment  of  Copper  Poisoning. — Al- 
btimin  and  milk  form  an  insoluble  com- 
pound with  copper  salts,  provided  they 
are  in  large  excess.  They  should  be  pre- 
ceded by  prompt  evacuation  of  the  stom- 
ach, but  the  stomach-pump  is  of  little 
avail  when  the  salt  is  in  coarse  particles. 
Vomiting  may  be  prompted  by  copious 
draughts  of  warm  water,  etc.,  and  lavage 
may  serve  an  excellent  purpose.  Ferro- 
cyanide  of  iron  is  also  recommended  to 
be  given  to  form  an  insoluble  copper 
cyanide;  the  hydrated  succinate,  the  pro- 
tosulphuret  and  hydrate  oxide,  and  pro- 
tosulphuret  have  also  been  employed. 
Opium  is  usually  necessary  to  allay 
gastro-intestinal  irritation  and  relieve 
pain. 

Any  antidote  to  be  of  avail  must  be 
given  at  once  and  act  quickly.  Milk 
and  eggs  are  almost  always  at  hand,  and 
are  the  most  efficacious  antidotes.  No 
time  should  be  lost  in  attempting  to 
separate  the  yelk  from  the  white  of  the 
egg,  but  the  egg  should  be  broken  into 
a  bowl  as  quickly  as  possible,  a  little 
water  added,  and  the  whole  stirred  up 
and  exhibited.  The  dose  should  be  re- 
peated several  times,  especially  when 
there  is  vomiting.  Soap  or  fixed  alkali 
may  be  given.  The  yellow  prussiate  of 
liotash,  when  pure,  is  harmless,  and  pre- 
cipitates instantly  an  insoluble  com- 
pound of  copper  from  solutions  of  its 
salt;  when  it  is  to  be  had  in  time,  it 
may,  therefore,  be  used  as  an  antidote 
to  the  sulphate.  II.  C.  Wood  ("Princ. 
and  Prac.  of  Therap.,"  '94). 

As  Emetics. — Copper  salts  act  as  emet- 
ics without  causing  much  depression  of 
the  nervous  system,  but  the  sulphate  is 
invarial}ly  preferred,  since  the  doses  and 
its  cheapness  render  it  more  manageable 
and  convenient. 

To  empty  the  stomach  in  ease  of 
poisoning,  make  ten  powders  of  a  mixt- 
ure of  .'!0  grains  of  copper  sulphate  and 
120    grains    of    white    sugar    (powdered 


COPPER.     THERAPEUTICS. 


327 


sugar),  and  give  a  powder  every  ten 
minutes  until  vomiting  is  produced. 
Kotli  ("Mod.  Mat.  Med.,"  '95). 

Therapeutics. — The  copper  prepara- 
tions have  had  a  varied  and  checkered 
reputation  as  remedial  agents,  and  have 
been  tried,  chiefly  on  empirical  grounds, 
in  a  large  number  of  maladies. 

ANiEMiA  AND  CHLOROSIS. — Formerly 
they  were  in  repute  as  '^blood-making" 
agents,  and  employed  in  anaemia  and 
chlorosis,  and  they  still  retain  the  con- 
fidence of  many  practitioners,  especially 
where  the  anajmia  is  characterized  by  a 
bluish  color  of  the  skin,  the  acetate  salt 
having  the  preference. 

For  chlorosis  and  functional  ancemia, 
arsenite  of  copper  is  given  in  doses  of 
Vw  to  'As  grain,  two  or  three  times 
daily;  but  in  these  conditions  heemo- 
globinomctrio  examinations  have  not 
shown  that  it  is  superior  to  other  forms 
of  arsenic.  Armstrong  (Foster's  "Prac. 
Therap.,"  vol.  i,  'Oti). 

Convulsive  and  Spasmodic  Dis- 
eases.— More  than  in  any  other  class  of 
maladies,  perhaps,  copper  has  held  its 
own  in  the  management  of  chorea,  epi- 
lepsy, hysteria,  croup,  etc.,  etc.  (see 
Laryngitis,  post).  In  epilepsy  espe- 
cially, the  ammoniosulphate  has  been 
employed,  oftentimes  with  advantage,  in 
doses  of  Vo  grain,  in  pill  form,  night  and 
morning,  increasing  every  second  day  by 
Vu  grain.  The  sulphate  in  gradually 
ascending  doses  has  been  used  in  both 
epilepsy  and  chorea;  it  is  advised  for  the 
former  malady  to  combine  it  with  qui- 
nine; it  was  likewise  a  favorite  remedy 
of  Sir  Benjamin  Brodie  in  obstinate  hys- 
teria. 

In  croup,  too,  the  sulphate  salt  was 
formerly  extensively  employed,  first  to 
obtain  relief  by  prompt  emesis,  and  next 
in  small  doses  every  fourth-  or  half-hour 
for  the  purpose  of  checking  excessive  se- 
cretion from  tlio  lining  membrane  of  the 


bronchial  tubes  and  cells.  The  reports 
regarding  the  use  of  the  drug  in  the  past 
are  most  favorable. 

Genito  -  Urinary  and  Venereal 
Diseases. — By  reason  of  their  astrin- 
gency,  copper  salts  are  frequently  em- 
ployed in  weak  solution  for  the  treat- 
ment of  gonorrhffia,  leucorrha?a,  cystitis, 
etc.,  and  in  solution  or  crystal  as  topical 
applications  to  chancres  and  other  syphi- 
litic sores  and  internally  in  lieu  of  the 
mercury  salts.  In  gonorrhma  and  leucor- 
rhcea,  a  solution  of  ammonium  sulphate, 
15  grains  to  2  or  3  ounces  of  fluid,  is 
occasionally  serviceable;  again,  a  solu- 
tion of  the  sulphate,  8  to  10  grains  to  an 
ounce  of  solution  of  suLacetate  of  lead, 
the  whole  diluted  with  8  ounces  of  water, 
is  often  employed  for  the  former  malady; 
in  leucorrhcea,  40  to  60  grains  to  a  pint 
of  tepid  water. 

For  syphilitic  ulcerations,  the  deli- 
quesced copper  nitrate  is  frequently  the 
most  suitable  application. 

In  syphilis  the  sulphate  of  copper  is 
superior  to  mercury  in  its  effects  on  the 
lymphatic  system.  The  cutaneous  sec- 
ondary manifestations  disappear  but 
slowly  under  its  influence,  but  it  pre- 
vents the  development  of  mucous  plaques 
and  laryngeal  accidents;  on  account  of 
its  great  activity,  it  is  advisable  to  in- 
terrupt the  treatment  one  or  two  days 
in  a  week.  Patients  at  first  have  a 
great  appetite;  but,  if  the  drug  be  too 
long  continued,  they  suffer  from  pros- 
tration, vertigo,  and  pallor,  with  rapid, 
weak  pulse.  It  is  best  administered  in 
doses  of  Vm  grain,  in  pills  or  potion  as 
may  seem  best,  three  times  daily;  sul- 
phate of  iron  may  be  added  if  it  seems 
advisable.  But  even  this  dose  is  dan- 
gerous when  there  is  syphilitic  cachexia, 
and  smaller  doses  should  be  given  to 
begin  with,  gradually  increasing  to  Vu 
grain  as  tolerance  becomes  established. 
Price  (N.  Y.  Med.  Rec,  Nov.  5,  '94). 

Diseases  of  Mouth  and  Throat. — 
In  the  sore  throat  of  scarlet  fever,  a 


328 


COPPEK.    THEKAPEUTIGS. 


gargle  of  sulphate  of  copper,  1  grain  to 
the  ounce  of  water,  is  sometimes  used. 
The  finely-powdered  salt,  incorporated 
with  honey  (10  grains  to  1  ounce),  is  an 
old  remedy  for  cancrum  oris,  aphthous 
ulcerations,  and  gangrenous  affections  of 
the  mouth. 

Sulphate  of  copper  may  be  used  as  a 
gargle  in  relaxed  sore  throat.  The 
aphtha  in  aphthous  stomatitis  are  bene- 
fited by  touching  with  a  copper-sulphate 
solution. 

Tlie  soluble  salts  of  copper  combine  in 
the  mouth  with  the  liquid  albuminous 
substances  of  this  cavity,  and  precipi- 
tate them  more  or  less  completely.  The 
sulphate  in  solid  form  may  be  applied 
with  advantage  to  the  spots  of  psoriasis, 
simple  or  specific,  that  affect  the  tongue. 
Applied  in  solution  along  the  edges  of 
the  gums  in  ulcerative  stomatitis,  it 
generally  quickly  heals  the  ulcerated 
surfaces,  though,  on  the  whole,  alum  is 
to  be  preferred.  A  weak  solution  painted 
over  the  mucous  membrane  will  remove 
tlie  white,  curdy-looking  coating  of 
thrush  and  prevent  its  renewal.  Ringer 
and  Sainsbury  ("Hand-book  of  Therap.," 
'97). 

Ear  Affections.  —  The  astringent 
properties  of  these  salts  may  render  them 
useful  local  applications  in  diseases  of  the 
external  ear;  but,  in  the  main,  there  are 
other  better  and  more  satisfactory  reme- 
dies. 

Eye  Diseases. — It  is  in  this  class  of 
maladies  that  the  copper  salts  have  been 
mostly  employed,  more  particularly  the 
ammoniosulphate,  sulphate,  and  acetate. 
In  opacity  of  the  cornea  a  solution  of  the 
first  named  (1  grain  to  the  ounce  of  water 
or  camphor-water)  has  appeared  in  some 
instances  to  hasten  the  process  of  absorp- 
tion. A  collyrium  of  sulphate  of  copper 
of  the  same  strength  has  also  been  found 
serviceable  in  the  purulent  ophthalmia 
of  infants.  In  granular  conjunctivitis 
the  pure  salt  in  crayon  form  afiplied  to 


the  inner  surface  of  the  lids  is  often 
most  satisfactory. 

Copper  citrate  used  in  109  cases  of 
eye  disease.  It  occurs  as  a  green  pow- 
der devoid  of  odor  or  taste,  soluble  in 
water  in  the  proportion  of  1  part  in 
9143,  and  in  salt  solution  in  the  propor- 
tion of  1  to  7700.  It  contains  35.09  per 
cent,  of  copper.  In  order  to  determine 
the  bactericidal  properties  of  this  sub- 
stance, the  author  experimented  with 
various  germs,  and  found  that  a  solu- 
tion of  1  to  9143  killed  the  staphylo- 
coccus pyogenes  in  from  three  to  six 
and  a  half  hours;  the  bacillus  pyocy- 
ancus  in  seven  hours,  etc.  Ointments 
containing  copper  citrate  in  use  for  a 
month  were  found  sterile.  The  remedy 
was  used  in  the  following  forms:  1.  A 
5  or  10  per  cent,  powder  with  sugar.  2. 
A  5  to  20  per  cent,  ointment  with  vase- 
lin,  lanolin,  or  glycerin,  according  to 
Arlt's  formula  (copper  citrate,  5  to  20, 
and  glycerin  ointment,  enough  to  make 
100).  3.  In  the  form  of  pencils  con- 
taining from  10  to  20  per  cent,  of  the 
active  substance  in  gum  arable,  starch, 
dextrin,  sugar,  distilled  water,  and 
glycerin  to  make  a  mass.  4.  In  thu 
form  of  washes,  in  water,  1  to  9143. 
The  author  has  employed  this  remeiiy 
in  fresh  trachoma,  in  pannus  tenuis,  in 
pannus  erassus,  in  corneal  opacities,  and 
in  chronic  conjunctivitis.  He  obtained 
good  results  in  G2.5  per  cent.,  35.2  per 
cent,  of  the  cases  giving  no  results, 
while  in  2.02  per  cent,  tlie  disease  be- 
came worse.  Krotoff  (Eoussky  Vratch, 
Apr.  20,  1903). 

Malarial,  Fevers. — At  one  time  the 
ammoniosulpliatc  salt  was  in  some  repute 
as  a  remedy  for  intermittent,  remittent, 
and  tropical  fevers,  though  on  what 
grounds  its  administration  was  recom- 
mended is  unknown.  Copper  salts  have 
also  been  recommended  in  chronic  ma- 
larial poisoning. 

Sepsis.  —  Like  most  metallic  sub- 
stances, copper  has  been  suggested  in 
septic  disorders,  but  latterly  its  use  has 
become  very  restricted. 


COPPER.    THERAPEUTICS. 


329 


In  threatened  puci-peral  fever  good 
results  were  obtained  by  washing  out 
the  uterus  and  vagina  with  a  5-per-cent. 
solution  of  copper  sulphate.  By  control 
experiments  it  was  found  that  this  salt 
is  antiseptic  and  fatal  to  streptococci 
and  staphylococci:  the  vibriones  are, 
however,  not  influenced  by  its  use.  Tar- 
nier  (Centralb.  f.  Gyniik.,  Jlay  8,  '91; 
Archives  of  Gyn.,  Oct.,  '91). 

Skin  Diseases. — Hero  the  value  of 
the  copper  salts  rests  chiefly  in  their 
power  as  antiseptics,  astringents,  anti- 
parasitics, and  stimulants.  The  nitrate 
is  powerfully  caustic;  hence  finds  a  place 
in  the  treatment  of  lupus  and  other  stub- 
born maladies.  The  sulphate  is  some- 
times very  efficacious  in  tinea  trycophy- 
tina,  icthyosis,  and  ringworm;  has  also 
been  recommended  in  scabies,  after  the 
scabs  are  removed.  In  molluscum  the 
crystal  salt  has  been  applied  in  substance 
with  excellent  results;  and  French  prac- 
titioners often  use  a  strong  solution  to 
remove  warts. 

Oleate  of  copper  is  generally  efficacious 
to  combat  ringworm,  and  is  best  em- 
ployed by  incorporating  with  an  equal 
quantity  (or  perhaps  double  its  weight) 
of  lard.  It  should  be  rubbed  into  the 
diseased  surface  thoroughly,  and  success 
depends  upon  the  persistence  with  which 
the  medicament  is  employed,  as  much  as 
upon  its  strength.  Joseph  Adolphus 
(Med.  Age,  Apr.  10,  '90). 

Oleate  of  copper  may  be  employed  as 
a  plaster  for  warts  and  corns.  An  oint- 
ment of  copper  oleate  {1  to  4  or  8  parts 
of  petroleum  cerate)  is  especially  useful 
in  ringworm,  if  lightly  rubbed  in  night 
and  morning,  and  is  reconunended  for 
the  removal  of  freckles.  Martindale  and 
Westcott  ("The  Extra  Pharm.,"  Lond., 
'95). 

Tape-worm. — A  comparatively-recent 
application  of  the  copper  salts  is  as  a 
ta?nifuge. 

Black  oxide  of  copper  will  expel  tape- 
worm when  other  remedies  fail.  A  good 
combination  is  black  oxide  of  copper, 
30  grains,  and  sufficient  solid  extract  of 


gentian  to  _  make  a  pill  mass.  Divide 
into  30  pills,  of  which  give  1  four  times 
daily, — every  fourth  hour, — at  the  same 
time  prohibiting  acid  food  and  drink 
during  the  time  the  remedy  is  taken; 
continue  the  treatment  for  a  week  if 
necessary.  The  worm  will  be  expelled 
completely.  Pearson  (Med.  Stand.,  Feb., 
'92). 

The  following  was  employed  with  ex- 
cellent results  for  tsenia:  Black  oxide 
of  copper,  3  grains;  prepared  chalk,  02 
grains;  alum,  G 'A  drachms;  glycerin, 
5  drachms;  to  make  240  pills;  of  these 
8  to  12  are  to  be  taken  daily.  The  pa- 
tient takes  2  pills  daily  for  4  days  of 
the  first  week,  and  4  pills  daily  for  4 
days  of  the  next  week,  abstaining  dur- 
ing this  time  from  acid  food  and  drinks. 
A  large  dose  of  castor-oil  is  then  given, 
when  the  tape-worm  will  be  evacuated 
entire.  Segments  of  the  worm  are  passed 
during  the  two  weeks  of  treatment. 
Schmidt  (Wiener  med.  Presse,  No.  5, 
'94). 

Tuberculosis. — In  this  affection  sul- 
phate of  copper  has  been  recommended 
on  account  of  its  emetic  action.  It  will 
be  recalled  that  half  a  century  ago  drugs 
of  this  class  were  held  to  be  of  value  in 
the  early  stages  of  phthisis. 

In  incipient  tuberculosis  copper  phos- 
phate is  claimed  to  act  as  a  specific  and 
dynamic  agent.  It  may  be  given  twice 
daily  in  pill  form  by  adding  to  a  suit- 
able mass  1  grain  of  crystallized  sodium 
phosphate  and  '/»  grain  neutral  acetate 
of  copper;  or  they  may  be  given  in 
mucilage  of  gum  arable;  or  V,  grain 
of  phosphate  of  copper  dissolved  in  10 
minims  of  glycerin  may  be  injected  sub- 
cutaneously.  Bull  recommends  the  sul- 
phate in  phthisis.  Armstrong  (Foster's 
"Prac.  Therap.,"  vol.  i,  '9G). 

In  the  diarrhoea  of  phthisis  sulphate 
of  copper  is  often  prescribed,  but  the 
dose  should  not  exceed  V.  grain,  and  it 
is  best  administered  as  a  pill  made  with 
an  equal  weight  of  opium.  Murrell 
("Man.  of  Mat.  Med.  and  Ther.,"  '90). 

Ulcerations. — As  a  wash  to  weak,  in- 
dolent, ill-conditioned,  or  irritable  ulcers, 
small,   excavated,   semiphagedenic,   and 


330 


CORNEA. 


specific,  non-specific  and  malignant,  the 
copper  salts  are  valuable.  The  liquor 
cupri  ammoniosulphas  of  the  old  London 
Pharmacopceia  (1  drachm  to  the  pint  of 
distilled  water)  is  an  excellent  prepara- 
tion, as  is  also  the  Egyptian  liniment  (see 
ante),  and  a  solution  varjd.ng  in  strength 
according  to  individual  demand  of  1  to 
10  grains  of  sulphate  to  the  ounce  of 
water.  The  nitrate  salt  is  used  for 
chancres  and  phagedenic  ulcers  in  a  pure 
state,  and  the  sulphate  is  sometimes  ap- 
plied in  powder  or  in  solid  crystal. 

A  powder  of  copper  sulphate  dusted 
over  sluggish  sores  destroys  unhealthy- 
granulations  and  is  a  powerful  local 
stimulant.  This  salt  is  much  appre- 
ciated in  veterinary  practice.  A  lotion 
made  of  the  strength  of  3  grains  of 
the  salt  to  an  ounce  of  water  may  be 
applied  to  chancres  or  ulcers.  The  ni- 
trate, owing  to  its  deliquescent  proper- 
ties, soon  becomes,  on  slight  exposure 
to  the  air,  a  styptic,  caustic  fluid,  which 
has  j'ielded  good  results  when  applied  to 
syphilitic  ulcerations,  on  the  tongue,  in 
the  mouth  and  throat,  and  on  the  geni- 
tals. It  dill'ers  from  the  sulphate  in  ex- 
citing a  stronger,  more  healthy,  and 
alterative  action  in  the  tissues  around 
the  ulcer  after  the  destruction  of  the 
latter.  An  excellent  detergent  lotion  is 
had  by  adding  2  minims  of  the  liquid 
copper  nitrate  to  an  ounce  of  water. 
Whitla  ("Pharm.,  Mat.  Med.,  and 
Thcrap.,"  '91). 

Copper  sulphate  makes  a  good  applica- 
tion to  indolent  ulcers.  It  removes  dead 
tissue,  and  by  its  stimulant  efl'ect  pro- 
motes lioalthy  granulations.  Locke 
("Mat.  Med.  and  Therap.,"  '95). 

DiAnnHCEA  AND  Dysentery.  —  In 
chronic  dysentery  and  diarrhoea  a  com- 
bination of  copper  sulphate  and  opium  is 
often  serviceable:  Vi  to  Vj  grain  of 
former  and  Va  grain  of  the  latter,  given 
thrice  daily;  but  it  occasionally  induces 
severe  griping  in  spite  of  the  opiate;  in 
Buch  case  2  or  3  grains  of  monobromated 
camphor  constitute  a  valuable  addition. 


The  drug  is,  perhaps,  most  serviceable  in 
the  diarrhoea  of  phthisis,  though  some  of 
the  older  authors  speak  highly  of  it  in 
the  chronic  diarrhroa  of  infants. 

Copper  sulphate  is  a  good  astringent 
in  advanced  and  obstinate  diarrhoea. 
It  may  be  prescribed  as  follows:  Copper 
sulphate  and  powdered  opium,  of  each, 
V:  grain;  extract  of  gentian,  3  grains; 
for  one  pill,  constituting  a  single  dose. 
Farquharson  ("Therap.  and  Mat.  Med.," 
'S9). 

Injected  into  the  rectum  in  the 
strength  of  5  to  20  grains  to  the  ounce 
of  fluid,  copper  sulphate  will  be  found 
of  service  in  those  cases  of  diarrhoja 
which  arise  in  the  lower  bowel  and  are 
dependent  on  ulceration.  It  is  also  some- 
times given  in  pill  form  by  the  mouth 
in  doses  of  from  V»  to  1  grain.  Hare 
('Tract.  Therap.,"  '94). 

Uterine  Disorders. — Copper  sul- 
phate is  in  considerable  repute  among 
some  gynecologists,  particularly  on  the 
continent  of  Europe.  It  is  especially  em- 
ployed in  the  treatment  of  catarrhal  dis- 
orders. 

Copper  sulphate  employed  in  10  casea 
of  endometritis,  7  of  which  were  blennor- 
rhagie  in  character,  and  1  each  puerperal, 
post-puerperal,  and  catarrhal.  In  all  the 
remedy  was  applied  locally  in  the  form 
of  pencils,  and  the  results  were  highly 
satisfactory.  This  salt  acts  superficially, 
and  does  not  produce  the  deep  scars 
caused  by  zinc  chloride;  its  efl'eots, 
though  less  powerful,  are  more  certain 
than  those  of  the  latter  drug,  and  it 
does  not  produce  atresia  of  the  uterine 
canal.  Annaud  (Bull.  GCn.  do  Th6r., 
May  15,  '92). 

G.  Arciiie  Stockwem;, 

New  York. 

CORNEA,  DISORDERS  OF  THE  (see 
also  Keratitis). — Most  injuries  of  the 
cornea  are  of  importance  chiefly  on  ac- 
count of  the  accompanying  injury  of 
deeper  structures,  such  as  the  iris  and 
crystalline  lens,  or  because  of  the  lodg- 
ment of  foreign  bodies,  or  through  infec- 


CORNEA.     BURNS.    TREATMENT.    FOREIGN  BODIES. 


331 


tion  giving  rise  to  Ivcratitis,  or  more  ex- 
tended inflammation  of  the  eye. 

Burns.  —  Injuries  frequently  cause 
corneal  ulcer  (see  below).  Ultimately 
it  may  lead  to  corneal  opacity  or  irregular 
astigmatism  (see  Astigmatism).  The 
same  is  true  of  burns,  either  by  heat, 
acids,  or  caustics.  A  burn  by  heat  or 
by  nitric  acid  may  cause  a  super- 
ficial coagulation  of  the  corneal  tissue, 
giving  an  impression  of  complete  opacity 
of  the  membrane,  but  upon  the  separa- 
tion of  the  injured  tissue,  which  may 
occur  in  a  few  hours  or  at  most  a  few 
days,  the  cornea  is  found  to  be  clear  and 
comparatively  uninjured.  Burns  by  lime 
are  frequent,  and  very  serious  in  their 
effects,  the  lime  forming  a  union  with 
the  tissue,  which  makes  it  difficult  to 
remove,  and  continuing,  therefore,  to  act 
as  a  caustic  for  a  considerable  length  of 
time. 

Treatment. — Simple  burns  by  steam  or 
hot  metal  after  removal  of  the  metal 
should  be  treated  by  keeping  the  eyes 
closed  under  a  light  bandage  and  cleans- 
ing twice  a  day  with  boric-acid  solution. 

Injury  by  quicklime  may  be  met  by 
the  filling  of  the  eye  with  olive-oil;  and 
especially  requires  the  earliest  possible 
removal  of  all  the  retained  caustic. 
Other  caustic  alkalies  may  be  neutralized 
by  very  dilute  acids,  as  vinegar  and 
water;  but  reliance  should  be  mainly 
placed  on  washing  with  water  or  solution 
of  boric  acid. 

Acids  may  be  neutralized  by  lime- 
water,  or  solutions  of  sodium  or  potas- 
sium bicarbonate,  or  soap-suds.  But  the 
best  means  is  by  free  washing  of  the  con- 
junctiva with  a  1-per-ccnt.  solution  of 
sodium  bichloratc. 

Foreign  bodies  are  so  frequently  im- 
bedded in  the  cornea  because  the  cornea 
occupies  nearly  two-thirds  of  the  space 
between  the  opened  eyelids,  and  a  much 


larger  proportion  of  that  space  when  the 
eyes  are  partly  closed,  as  they  are  when 
the  entrance  of  a  foreign  body  is  antici- 
pated. Again,  the  tissue  of  the  cornea 
is  of  such  consistence  as  to  retain  such 
particles  as  may  penetrate  it,  whereas 
the  conjunctiva  and  subconjunctival  tis- 
sue are  so  loose  that  foreign  bodies  im- 
bedded in  them  easily  work  out. 

When  a  foreign  body  is  imbedded  in 
the  cornea  it  commonly  causes  irritation 
and  suppurative  inflammation,  by  which 
it  becomes  loosened  and  easily  drops  out, 
or  is  wiped  away  by  the  lids.  If,  how- 
ever, it  lie  at  the  bottom  of  a  consider- 
able loss  of  substance  it  may  lie  there 
for  some  time,  although  quite  detached 
from  the  corneal  tissue.  Under  these 
circumstances  it  becomes  a  source  of  ir- 
ritation, causing  chronic  weakness  of  the 
eye,  photophobia,  and  excessive  lacry- 
mation,  and  the  development  of  vessels  in 
the  adjoining  part  of  the  pericorneal 
space,  which  push  out  to  the  seat  of  the 
foreign  body,  giving  an  appearance  of  a 
chronic  phlyctenular  ulcer  or  superficial 
vascular  keratitis. 

Among  200  cases  of  foreign  body  in 
the  cornea  180  presented  themselves  for 
its  removal  within  1  week,  11  in  the 
second  week,  7  in  the  third  week,  and 
but  2  after  more  than  3  weeks.  Ten 
cases  are  reported  of  foreign  bodies  re- 
tained in  the  coinca  from  3  weeks  to 
IS  months,  and  a  few  instances  referred 
to  in  literature  in  which  they  have  been 
retained  even  longer.  Edward  JacksOD 
(Brit.  Med.  Jour.,  Jan.  8,  '08). 

Cases  in  which  the  laborers  employed 
to  knock  down  chestnuts  have  been 
struck  in  the  eye  by  the  falling  chestnuts 
and  the  little  spines  remained  in  the  cor- 
nea, their  bases,  as  a  rule,  being  flush 
with  its  surface.  For  locating  these 
bodies,  Zehender's  binocular  lens,  made 
by  Western,  of  Rostock,  are  of  great 
service,  and  the  illumination  should  con- 
sist of  convergent  rays  concentrated  by 
a   large  convex  lens.     The  prickles  are 


332 


CORNEA.     FOREIGN  BODIES.     DIAGNOSIS. 


difficult  to  seize  even  with  the  finest  for- 
ceps; Bowman's  needle  entered  obliquely 
is  useful.  It  is  better  to  withdraw  those 
which  do  not  penetrate  the  cornea  into 
anterior  chamber  before  those  which  do. 
To  disinfect  the  patn  of  the  prickle  after 
removal,  a  fine  tattooing  needle  may  be 
rotated  in  the  wound  like  a  gimlet,  thus 
scraping  it,  while  the  groove  of  the 
needle  allows  the  antiseptic  to  find  its 
way  down  into  the  wound.  The  gal- 
vanocautery  may  also  be  called  for. 
Deschamps   (Ann.  d'Ocul.,  Apr.,  '99). 


Cilia  in  the  ant 


niber.     (Meyer.) 


Diagnosis. — The  search  for  a  foreign 
body  in  the  cornea  should  be  made  by 
all  the  following  methods:  Oblique  il- 
lumination, the  ophthalmoscope,  and 
with  the  eye  placed  so  as  to  reflect  from 
its  surface  an  area  of  light,  as  before  a 
large  window.  If  the  foreign  body  has 
been  imbedded  many  hours  or  days  there 
also  will  be  pericorneal  redness,  most  de- 
cided at  the  part  of  the  corneal  margin 
nearest  the  foreign  body.  In  using 
oblique  illumination    foreign    bodies   of 


light  color  are  rendered  evident  when 
the  light  is  strongly  concentrated  on  the 
cornea  and  the  iris  in  comparative 
shadow.  Dark  particles  are  rendered  dis- 
tinct by  concentrating  the  light  on  the 
iris  behind,  thus  furnishing  a  light  back- 
ground. Light  foreign  bodies  are  best 
seen  against  the  black  pupil;  dark  ones 
against  the  illuminated  iris.  It  is  there- 
fore necessary  to  vary  the  oblique  illu- 
mination and  to  look  at  the  cornea 
from  different  directions. 

With  the  ophthalmoscope  all  foreign 
bodies  except  particles  of  glass  appear 
black  against  the  red  reflex  from  the 
pupil.  By  turning  the  eye  in  different 
directions,  this  reflex  must  be  obtained 
through  different  parts  of  the  cornea. 
Sometimes  with  the  ophthalmoscope  the 
appearance  of  a  foreign  body  is  caused 
by  a  slight  disturbance  of  the  corneal 
surface;  so,  that  after  the  position  of 
such  a  black  speck  has  been  ascertained 
it  must  be  examined  by  oblique  illumina- 
tion. 

In  young  children  where  much  diffi- 
culty is  experienced  in  examining  the 
cornea  the  child  should  be  laid  across 
the  nurse's  lap  in  such  a  way  that  its 
legs  are  between  her  body  and  left  arm, 
her  right  hand  being  free  to  control  the 
child's  hands.  The  examiner  sits  op- 
posite with  a  towel  or  rubber  sheet 
across  his  lap  and  places  the  child's  head 
between  his  knees.  In  this  way  the 
child  is  prevented  from  kicking  and 
struggling,  and  its  head  is  held  steady, 
leaving  the  examiner's  bauds  free  to 
separate  tlie  lids,  make  the  necessary 
examination,  and  apply  the  proper  reme- 
dies. C.  A.  Wood  and  T.  A.  Woodruir 
(Med.  Standard,  Oct.,  1901). 

The  reflection  of  an  area  of  light,  as 
a  large  window  opening  to  the  sky,  or  a 
strongly-illuminated  card  held  close  be- 
fore the  eye,  is  uniform  from  the  normal 
cornea.  But  when  by  the  presence  of  a 
foreign  body  the  corneal  surface  is  rough- 
ened, the  irregularity  caused  in  the  re- 


CORNEA.     FOKEIGN  BODIES.     TREATMENT.     OPACITIES. 


333 


flection  is  very  noticeable,  and  furnishes 
the  most-readily-applicable  method  of 
recognizing  the  presence  and  location  of 
such  an  injury  or  foreign  body.  If,  how- 
ever, the  disturbance  of  the  surface  be 
slight,  it  is  liable  to  be  masked  by  the 
layer  of  mucus  which  covers  the  normal 
cornea;  and  to  avoid  this  source  of  error 
the  corneal  surface  should  be  dried  by 
touching  it  with  a  bit  of  absorbent  cot- 
ton. 

Treatment. — In  general,  foreign  bod- 
ies lodged  in  the  cornea  should  be  at  once 
removed.  This  is  usually  a  very  simple 
operation  with  the  eye  placed  under  the 
influence  of  local  anresthesia.  A  single 
drop  of  a  2-per-cent.  solution  of  cocaine, 
or  a  1-per-cent.  solution  of  holocain, 
placed  directly  upon  the  cornea  produces 
the  necessary  anssthesia  in  from  three 
to  five  minutes.  Occasionally  a  foreign 
body  can  be  wiped  away  by  a  little  ab- 
sorbent cotton  wrapped  closely  and 
firmly  around  the  end  of  a  probe  or 
match-stick.  If  more  firmly  imbedded 
the  ordinary  spud  is  to  be  used  by  thrust- 
ing it  into  the  wound  alongside  of  the 
foreign  body,  and  by  something  of  a 
wedge-like  action,  pushing  the  foreign 
body  out. 

Foreign  bodies  of  a  certain  character, 
as  splinters  of  wood  or  the  beards  of 
gi'ain  or  grasses,  may  require  to  be  ex- 
tracted as  a  splinter  is  extracted  from  the 
skin,  by  making  an  incision  along  it  with 
a  needle  or  cornea-knife,  so  as  to  freely 
expose  it,  and  then  lifting  it  oxit  of  its 
bed.  When  the  foreign  body  extends 
somewhat  into  the  anterior  chamber,  the 
eye  should  be  kept  quiet  until  the 
aqueous  humor  has  refilled  the  chamber. 
Then  a  broad  needle  is  to  be  thrust  un- 
derneath the  foreign  body,  and  held  with 
its  point  imbedded  in  the  posterior  sur- 
face of  the  cornea,  while  the  foreign 
body  is  extracted. 


Occasionally  when  the  condition  of  the 
patient,  or  the  lack  of  proper  instru- 
ments, or  of  a  local  aneesthesia  renders 
the  extraction  of  the  foreign  body  im- 
possible, it  is  proper  to  cleanse  the  sur- 
face of  the  eye  as  thoroughly  as  possible, 
and  allow  it  to  remain  for  a  few  days 
until  the  process  of  suppuration  has  loos- 
ened it.  Then  it  can  be  washed  or  wiped 
out.  But  such  a  process  is  always  at- 
tended with  danger  of  infection  of  the 
deeper  structures  of  the  eye  and  serious 
damage  or  complete  functional  loss  of 
the  organ. 

Bits  of  iron  imbedded  in  the  cornea 
very  quickly  give  rise  to  a  brown  stain, 
probably  due  to  oxide  of  iron.  This 
stain  may  remain  after  the  removal  of 
the  foreign  body,  but  is  always  cast  off 
within  a  few  days.  It  is  better  to  remove 
it  at  once  by  scraping,  as  it  often  proves 
a  source  of  irritation  and  always  ulti- 
mately separates  as  a  slough. 

Study  of  the  eflects  of  the  deposit  of 
rust  in  the  cornea  by  placing  particles 
of  iron  in  the  corners  of  cuts.  Five 
minutes  were  sufficient  to  make  the 
iron  reaction  appreciable,  metallic  iron 
being  chemically  irritant,  while  iron 
oxide  was  not.  The  ring  of  rust  found 
about  the  foreign  body  consisted  of  hy- 
drated  oxide  of  iron,  and  was  chemically 
innocuous.  The  corneal  epithelium 
showed  itself  to  resist  extraordinarily 
the  invasion  of  the  oxide  of  iron. 
Gruber  (Archiv  f.  Ophth.  [GrUfe],  B.  11, 
H.  2,  '94). 

Powder-grains  imbedded  in  the  cornea 
at  first  cause  much  irritation  and  in- 
flammation. But  if  this  has  passed  away 
the  remaining  stain,  consisting  of  mi- 
nute particles  of  carbon,  may  be  retained 
indefinitely,  without  being  a  source  of 
further  trouble  or  danger. 

Cornea,  Opacities  of. 

The  bulk  of  the  cornea,  being  a  highly- 
specialized  tissue  closely  related  to  or- 


334 


COKXEA.     OPACITIES.    VARIETIES. 


dinary  connective  tissue  like  that  com- 
posing the  sclera,  is  liable  by  slight  de- 
generation to  lose  its  transparency.  All 
considerable  injuries  or  losses  of  sub- 
stance of  the  cornea  are  repaired  by  cic- 
atricial connective  tissue,  which  usually 
fails  to  become  entirely  transparent. 
Hence,  corneal  opacities  are  a  probable 
sequel  of  all  other  diseases  or  injuries 
of  the  cornea.  Slight  haziness  of  the 
cornea  is  spoken  of  as  nelula.  A  more 
dense  localized  haziness,  amounting  to 
almost  complete  opacity  is  called  a 
macula.      More    dense    and    complete 


Congenital  opacity  of  the  cornea  ia 
rare.  It  may  arise  from  intra-uterine 
inflammation,  or  from  an  arrest  of  the 
clearing  of  the  cornea,  which  is  origi- 
nally opaque.  This  clearing  beginning 
at  the  corneal  margin,  such  opacities  usu- 
ally involve  the  centre.  They  may  di- 
minish in  early  childhood,  although  this 
is  unusual:  and  occasionally  somewhat 
similar  opacities  are  said  to  occur  after 
birth  and  to  increase. 

Two  cases  of  symmetrically-placed 
opacities  of  the  cornea,  occurring  in 
mother  and  son.     The  boy  was  8  years 


Symmetrically-placed  opacities  of  the  cornea.  The  upper  tigures  represent  the  appear- 
ances presented  by  the  eyes  of  the  mother,  the  lower  those  of  the  son.  The  pupils 
are  represented  as  dilated,  in  order  to  give  the  configuration  of  tlie  opacities  against 
a  dark  background  as  clearly  as  possible.     {Oliver.) 


opacity,  from  its  usual  color,  white,  is 
called  leucoma.  The  density  of  the 
opacity  indicates  the  severity  of  the 
lesion  causing  it  and  the  age  of  the 
patient,  recovery  from  the  severe  lesions 
being  more  complete  in  early  life. 

Varieties. — The  opacity  usually  occur- 
ring with  age  as  a  gray  arc  slightly  within 
the  upper  and  lower  margins  of  the 
cornea  is  the  arcus  senilis.  It  extends  in 
eome  persons  to  form  a  complete  ring, 
annulus  senilis,  separated  by  a  zone  of 
comparatively-clear  cornea  from  the 
sclera.  Sometimes  it  occurs  in  early  life; 
and  even  in  early  childhood. 


of  age,  and  presented  in  each  cornea  (as 
shown  in  lower  portion  of  figure)  a  cen- 
tral macula  surrounded  by  a  ring  of 
superficial  pin-point  opacities.  These 
had  been  observed  for  a  long  time,  but 
one  year  previously  had  enlarged,  fol- 
lowing an  attack  of  malaria  fever. 
Laveran's  corpuscles  could  not  bo  de- 
tected and  there  was  no  evidence  of  con- 
genital By|)hilia.  Examination  of  the 
mother's  eyes  showed  similar  opacities 
in  each  cornea,  which  had  been  present 
as  long  as  she  could  remember.  Those 
are  shown  in  the  upper  portion  of  the 
figure.  Oliver  (Amer.  Jour,  of  Ophth., 
Aug.,  '02). 

Record  of  an  instance  where  the  first, 
second,  and  fourth  children  of  a  family 


CORNEA.     OPACITIES.    VARIETIES. 


335 


were  blind  from  congenital  opacity  of 
the  cornea,  most  dense  at  the  centre. 
There  was  a  deep  anterior  chamber  and 
rather  large  eyeballs.  The  third  child 
had  normal  eyes.  The  mother  was 
healthy,  the  father  when  20  years  old 
had  suffered  from  inflammation  of  both 
eyes,  lasting  eight  months;  and  leaving 
a  central  clouding  of  the  cornea.  Wer- 
nicke (Ann.  d'Oculistique,  Oct.,  '90). 

Microscopical  examination  of  the  cor- 
ner of  an  infant  suffering  from  con- 
genital opacity,  dying  on  the  third  day, 
and  without  other  congenital  anomalies. 
The  chief  lesions  were  found  in  the  pos- 
terior layers  of  the  cornea  and  were 
allied  to  those  of  interstitial  keratitis. 
A.  Telpljaschin  (Archives  of  Ophthal., 
Jan.,  '97). 

Attention  called  to  a  form  of  corneal 
cloudiness  occasionally  seen  in  patients 
complaining  of  asthenopic  symptoms 
rather  more  severe  than  those  usually 
attending  refractive  errors.  This  corneal 
turbidity  appears  to  be  simply  an  exag- 
geration of  tlie  normal  cloudiness,  and  can 
be  seen  with  a  highly  magnifying  lens 
and  lateral  illumination.  Henry  Gradle 
(Phila.  Med.  Jour.,  July  10,  '98). 

Opacities  due  to  inflammation  of  the 
cornea  are  most  dense  immediately  after 
the  subsidence  of  the  inflammation,  from 
which  time  they  diminish  with  greater 
or  less  rapidity  according  to  the  age 
of  the  patient  and  the  nature  of  the 
opacity.  Sometimes  quite  a  noticeable 
macula  will  be  left  by  an  inflammation 
occurring  a  few  weeks  previously  that 
has  been  quite  overlooked  or  forgotten. 
The  general  clouding  of  the  cornea  from 
interstitial  keratitis  clears  first  from  the 
margin,  and,  usually  in  the  course  of 
several  months,  or  one  or  two  years,  is 
reduced  to  a  nebula,  although  perfect 
recovery  is  rare. 

Peculiar  greenish  discoloration  of  the 
cornea  following  traumatism,  thought  to 
be  related  to  corneal  hremorrhage  and 
attributed  to  the  presence  of  hrematic 
pigment.  Regarded  as  one  of  the  acci- 
dents partly  dependent  upon  hoemorrhage 


into  the  anterior  cliamber  and  neigh- 
boring tissues,  especially  into  the  corneo- 
scleral junction  in  front  of  Descemet's 
membrane  and  around  the  canal  of 
Schlemm.  Vossius  (Archiv  f.  Ophth. 
[Grafe],  vol.  xxxv.  No.  2,  '89). 

Study  of  two  eases  of  staining  of  the 
coi-nea  by  blood-pigment.     In   the  first 
case  the  central  part  of  the  cornea  was 
stained  a  brownish  color,  leaving  a  nar- 
row, clear,  and  colorless  rim  at  the  pe- 
riphery.     Intra-ocular    tension    equaled 
— 1,  and  there  was  no  light-perception. 
After  enucleation  the  discoloration  of  the 
cornea  was  seen  to  extend  throughout 
the     whole     thickness.       The     anterior 
chamber  was  filled  with  blood-clots,  the 
lens  was  opaque  and  calcareous,  and  the 
vitreous  was  shrunk.     There  was  com- 
plete detachment  of  the  retina,  and  pro- 
jecting from  its  outer  surface  were  two 
transparent    cysts.      Examination    with 
the    microscope    showed    that,    dissemi- 
nated throughout  the  discolored  portion 
of  the  cornea,  there  were  numerous  small, 
refracting  granules,   mostly  of  an   oval 
or   circular  form.     In   the   second   case 
in  the  centre  of  each  cornea  there  was 
an   irregular-shaped   patch    of   a   rusty- 
brown   color,   surrounded   by   a  zone  of 
bright  red.     There  can  be  no  doubt  but 
that  the  pigment  was  derived  from  the 
blood,  having  found  that  in  all  the  cases 
reported  there  was  blood  in  the  anterior 
chamber.      Treacher    Collins     (Transac. 
Ophth.  Soc.  of  United  Ivingdom,  vol.  ii, 
'91). 
Opacities  connected  with  anterior  syn- 
echia remain  dense  throughout  life.  Vas- 
cular opacities  connected  with  granular 
or  phlyctenular  conjunctivitis  are  capa- 
ble of  great  improvement  after  the  cure 
of  the  conjunctival  diseases  that  cause 
them.    Those  due  to  granular  conjunc- 
tivitis, or  trachoma,  commonly  involve 
the  upper  half  of  the  cornea,  the  part  in 
contact  with  the  roughened  upper  lid, 
and  sometimes  encroach  slightly  on  the 
lower  lid.     Those  due  to  phlyctenular 
keratitis  take  the  form  of  a  fasciculus  of 
vessels  running  out  from  one  or  more 
parts  of  the  corneal  margin. 


336 


COKXEA.     OPACITIES.     VARIETIES. 


Anterior,  or  corneal,  staphyloma  is  the 
bulging  opacity  which  follows  perfora- 
tion of  the  cornea,  either  by  traumatism 
or  by  ulcerative  inflammation,  leading 
to  prolapse  of  the  iris  and  union  of  the 
iris  and  new-formed  tissue  in  the  corneal 
scar.  It  does  not  necessarily  ensue  in 
all  cases  of  prolapse  of  the  iris  into  a 
corneal  opening.  After  cataract  extrac- 
tion very  extensive  prolapse  of  the  iris 
may  occur,  and  yet,  without  any  active 
treatment,  the  prolapse  will  in  time 
entirely  flatten  down,  leaving  a  slight 
opacity  with  adhesion  of  the  iris  at  the 
side  of  the  corneal  incision.  The  same 
favorable  termination  is  also  seen  in 
cases  of  traumatic  perforation,  other 
than  operative;  and  sometimes  in  per- 
foration due  to  small  ulcers.  The  de- 
termining factor  as  to  the  occurrence  of 
staphyloma  appears  to  be  the  general 
condition  of  the  cornea,  and  possibly  of 
the  iris,  that  becomes  adherent  to  it.  If 
these  are  the  seat  of  extensive  inflam- 
matory changes,  there  is  strong  proba- 
bility of  increasing  bulging  of  the  cica- 
trix. 

In  young  children  the  general  adhe- 
sion of  the  iris  to  the  cornea  is  followed 
by  bulging  of  the  whole  cornea  and  even 
great  enlargement  of  the  eyeball;  in 
older  persons  staphylomata  are  likely  to 
be  more  strictly  localized,  and,  if  the 
bulging  is  great,  they  rupture. 

Fine  opacities  upon  the  membrane  of 
Dcscemet  can  be  seen  in  all  cases  of 
iritis.  They  are  usually  overlooked,  be- 
cause the  required  examination  is  not 
made.  The  best  method  of  examination 
is  with  the  ophthalmoscope,  a  strong 
convex  lens  being  used  at  the  sight-hole. 
Such  deposits  appear  early  in  iritis, 
frequently  before  synechia!  have  been 
formed,  and  they  disappear  some  time 
after  the  inflammation  has  subsided. 
Larger  opacities  are  found  in  many 
cases.  An  irregular  striated  opacity  of 
the  cornea  also  attends  certain  cases  of 


iritis,  this  opacity  being  situated  in  the 
proper  corneal  substance.  H.  Frieden- 
wald  (Archives  of  Ophthalmology,  April, 
•96). 

The  binocular  magnifying  lens  not 
only  allows  the  surgeons  to  discriminate 
by  accurate  recognition  of  the  depth  of 
a  corneal  opacity,  but  by  its  binocular 
impression  causes  points  to  be  appre- 
ciated that  would  otherwise  not  attract 
the  attention  of  the  observer.  E.  Jack- 
son (Trans,  of  Section  on  Ophthalmology, 
Amer.  Med.  Assoc,  '97). 

Opacity  following  the  use  of  a  lead 
lotion  upon  an  tilcerated  cornea  has  long 
been  recognized  and  ascribed  to  the  de- 
posit of  metallic  lead  in  the  denuded 
corneal  tissue.  But  this  explanation  is 
now  shown  to  be  incorrect,  for  at  least 
some  of  these  cases. 

A  case  of  corneal  ulceration  was 
treated  with  iodoform  ointment,  but  no 
preparation  of  lead  was  used.  The 
lower  half  of  the  cornea  presented  a 
white  metallic  appearance  like  that 
ascribed  to  the  use  of  a  lead  lotion. 
Darier  (Rev.  G6n.  d'Ophtal.,  July  31, 
'9G). 

lodine-vasogen  is  a  valuable  applica- 
tion in  infiltrated  and  spreading  ulcers 
of  the  cornea,  whether  associated  willi 
purulent  conjunctival  secretion  or  not. 
It  is  particularly  indicated  in  those 
cases  in  which  the  galvanocautery  is 
contra-indicated  by  the  situation  of  the 
infiltrate.  It  rarelj'  causes  pain,  if  not 
applied  in  excess,  and  never  causes  any 
unpleasant  reaction  or  untoward  effects. 
Preliminary  anesthetization  of  the  cor- 
nea with  cocaine  is  rarely  required,  and 
in  general  is  better  omitted.  The  appli- 
cation is  best  made  every  other  day 
\intil  the  infiltrate  begins  to  shrink  de- 
cidedly, and  then  should  be  made  every 
three  or  four  days  until  the  infiltrate 
disappears.  Alexander  Duane  (Ar- 
fliivcs  nf  Ophthalmology,  vol.  xxxi.  No. 
.'■),  1902). 

Opacity  from  pigment-deposit  in  the 
cornea  is  of  two  kinds.  In  one,  small 
spots  of  black  or  l)rown  pigment  are  de- 


CORNEA.    OPACITIES.    VARIETIES. 


337 


posited  in  the  cornea,  late  in  the  history 
of  an  intra-ocular  inflammation  which 
has  usually  been  attended  with  high  ten- 
sion. Such  pigment-deposits  are  likely 
to  be  permanent.  A  temporary  general 
staining  of  the  cornea  by  blood-pigment 
occurs  after  extensive  hsemorrhage 
within  the  eyeball.  The  staining  is  at 
first  comparatively  uniform,  and  clears 
up  from  the  margin  of  the  cornea. 

An     extensive     prolapse  of     the     iris 
through  wound   of  tlie   eye  by   scissors 
was  removed  by  iridectomy.     Tliis  was 
followed  by  repeated  hjemorrhages  into 
the  anterior  chamber,  and  subsequently 
the   patient,   a    girl    of   3 '/:  years,   had 
measles.     There   was  marked  discolora- 
tion of  the  cornea  beginning  the  tenth 
day  after  operation,  and  increasing  until 
the     membrane     assumed     a     greenish- 
brown    color,    except    near    the    corneal 
margin.     At  the  end  of  fifteen  months 
the    blood-staining    of    the    cornea    had 
cleared   up  except  at  the  centre,  where 
there   was   an   oval   patch   of  brownish 
hue    with    sharply-marked    edges;    and 
this  part  had  also  become  translucent. 
G.   E.   de   Schweinitz    {Ophthal.   Record, 
Dec,  '97). 
Haziness  of  the  cornea  due  to  inflam- 
matory deposit  tends  to  clear  up  at  first 
rapidly  and  then  more  slowly  after  the 
subsidence  of  the  inflammation  causing 
it.     This  tendency  to  clear  up  may  be 
accelerated,  or  continued  after  it  would 
otherwise  cease,  by  certain  applications 
to  the  cornea.     One  of  the  oldest,  the 
dusting  of  calomel  upon  the  surface,  is 
still  useful  in  the  opacities  left  by  phlyc- 
tenular keratitis.     Other  irritants  have 
been  used  in  a  similar  manner.    Massage 
of  the  cornea,  either  by  rubbing  through 
the  closed  lid,  or  by  stroking  and  rubbing 
the  cornea  with  a  corneal  spatula,  or 
specially  devised  instrument,  has  also  a 
positive  effect  in  renewing  the  process 
of  absorption  when  this  becomes  slug- 
gish.   Electrolysis  is  also  of  marked  value 
in  clearing  up  such  opacities,  if  they  are 


unattended  with  anterior  synechiae,  and 
especially  if  due  to  infiltration  of  the 
cornea  rather  than  repair  of  extensive 
loss  of  substance  by  ulceration. 

When  it  is  impossible  to  secure  further 
absorption  of  the  opacity,  it  may  be  ren- 
dered less  noticeable  and  annoying  by 
tattooing  the  affected  region. 

[L.  de  Wecker  insists  that  tattooing 
for  optical  purposes  should  be  recognized 
as  distinct  from  tattooing  merely  to  im- 
prove the  appearance  of  a  sightless  eye. 
He  believes  that,  by  rendering  opaque 
the  semitransparent  corneal  tissue  in 
front  of  the  pupil,  the  diffusion  of  light 
can  be  diminished  and  the  acuteness  of 
vision  improved.  Tattooing  for  this  pur- 
pose may  requiie  to  be  combined  with 
optical  iridectomy  or  the  division  of  the 
sphincter  of  the  iris.  In  performing  the 
operation  the  area  to  be  tattooed  must 
first  be  distinctly  marked  out,  and  then 
must  be  colored  a  uniform  intense  black. 
Edward  Jackson.] 

Iridectomy  should  not  be  performed 
for  optical  purposes  in  children  whose 
corneas  are  opaque;  yellow  ointment 
should  be  used,  followed  by  massage 
through  the  closed  lids  for  thirty  seconds, 
the  eye  being  washed  afterward  with 
boric-acid  solution.  This  treatment  is 
repeated  daily  until  the  eye  is  injected, 
and  then  discontinued,  to  be  renewed 
when  the  irritation  disappears.  Of  112 
children  with  leucomas  of  different  ex- 
tent and  depth,  91  were  cured,  11  im- 
proved, and  10  did  not  continue  treat- 
ment. I.  Malgat  (Rec.  d'Ophtal.,  iMar., 
'9S). 

Tattooing  of  the  cornea  should  not  be 
entered  upon  too  lightly.  One  should 
refuse  to  operate  in  any  case  in  which 
the  iris  is  incorporated  in  the  cicatri.x. 
Trousseau  (Ann.  d'Ocul.,  Mar.,  '99). 

Dionin  used  to  clear  up  new  and  old 
corneal  opacities.  The  solid  drug  is  ap- 
plied in  doses  of  about  0.00.5  gramme 
C/io  grain)  once,  or  rarely  twice,  a  week 
to  the  conjunctiva.  In  this  way  there 
is  not  acquired  that  speedy  tolerance  to 
its  action.  The  pain  lasts  from  two  to 
live  minutes:  the  oedema  reaches  its 
height  in  fifteen  or  twentv  minutes,  and 


338 


CORNEA.    TUMORS. 


lasts  from  four  or  eigUt  to  twelve  hours, 
or  even  longer.  Sneezing  is  a  common 
sequel,  especially  in  adults.  In  those 
cases  -where  the  patient  must  he  treated 
at  home  an  ointment  containing  10  per 
cent,  of  dionin  is  ordered,  with  directions 
that  a  small  mass  should  he  placed 
inside  the  lids  and  then  gently  rubbed. 
In  five  cases,  among  sixty  in  all,  no 
oedema  resulted.  F.  R.  v.  Arlt  (Wochen. 
f.  Therapie  u.  Hygiene  des  Auges,  Dec. 
11,  1902). 

The  well-known  solvent  powers  of 
lithia  in  cases  of  chalky  deposits  else- 
where, and  the  frequency  with  which 
limp  salts  are  found  in  the  chemistry  of 
corneal  opacities,  suggested  its  use  in 
suitable  cases.  The  -writer  employed 
the  benzoate  locally,  after  some  pre- 
liminary uncertainty,  in  solutions  of 
2Vj  to  10  per  cent.,  and  obtained 
most  satisfactory  results  comparatively 
quickly.  It  acts  probably  by  becoming 
broken  up  by  the  action  of  the  tissues 
into  formic  acid  and  then  into  water 
and  carbonic  acid,  this  acid  giving  to 
the  solution  its  solvent  power  over 
chalky  substances.  In  addition  there 
may  be  a  direct  action,  as  both  car- 
bonate and  phosphate  of  lime,  insoUi- 
ble  in  water,  are  dissolved  at  once  by  a 
watery  solution  of  benzoate  of  lithia. 
It  dissolves  also  both  uric  acid  and 
urates,  and  is  thus  useful  in  definitely 
gouty  alTections.  The  application  is 
not  painful.  Mazet  (La  Clin.  Ophtal., 
ilay  2.5,  1903). 

Cornea,  Tumors  of. 

New  growths  situated  wholly  or  chiefly 
in  the  cornea  are  rare.  They  may  be  of 
importance  because  of  the  disfigurement 
they  produce  from  interference  with 
■dsion  or  by  danger  of  extension  when 
of  a  malignant  character. 

Frequently  tumors  of  the  conjunctiva 
extend  over  the  cornea,  and  so  belong 
partly  to  both  regions.  It  has  even  been 
doubted  whether  primary  tumors  of  the 
cornea  ever  occur.  But  well  attested 
cases  are  on  record.  The  most  frequent 
form  of  corneal  tumor  is  the  dermoid, 
which  usually  starts  about  the  sclero- 


corneal  junction  and  extends  both  wa3's. 
It  is  generally  believed  to  be  always  con- 
genital; but  may  slowly  increase  in  size 
for  many  years;  such  tumors  are  com- 
monly removed  for  cosmetic  reasons. 

Malignant  neoplasms  involving  the 
cornea  are  usually  secondary. 

Perhaps  carcinoma  of  the  cornea  is 
always  secondary  to  such  growths  of  the 
conjunctiva  or  some  more  distant  part. 
Fibroma  or  sarcoma  may  be  primary. 

Report  of  a  case  of  fibroma  removed 
from  the  cornea  of  a  woman,  aged  50, 
where  it  had  been  slowly  growing.  The 
margin  of  the  cornea,  about  one  milli- 
metre wide,  was  transparent  all  around. 
The  tumor  was  flat,  whitish,  and  two 
millimetres  thick.  It  was  easily  dis- 
sected from  the  cornea,  which  was  trans- 
parent, and  its  removal  allowed  the  pa- 
tient to  read  large  letters.  The  micro- 
scope showed  it  to  be  purely  fibrous,  and 
derived  probably  from  the  corneal  sub- 
stance. D.  Meigham  (Glasgow  Med. 
Jour.,  vol.  ii,  p.  223,  '90). 

Report  of  a  case  of  primary  sarcoma 
commencing  at  the  corneal  limbus. 
Twenty-two  other  cases  found  in  litera- 
ture. From  a  study  of  these,  conclusion 
reached  that  sarcoma  of  the  limbus  is 
comparatively  rare  and  remains  confined 
to  the  external  structures.  Metastases 
practically  never  occur.  Recurrences  are 
frequent,  but  do  not  justify  enucleation, 
unless  the  growth  has  attained  extensive 
proportions  or  vision  has  been  de- 
stroyed. A.  N.  Strouse  (Archives  of 
Ophth.,  p.  217,  '97). 

Corneal  scars,  although  often  perma- 
nent, and,  if  large,  subject  to  distension, 
very  rarely  become  the  seat  of  keloid 
changes.  But  a  tumor  of  that  kind  is 
possible. 

A  girl  sufl'orcd  from  ophthalmia  neona- 
tor\ini,  which  left  the  cornea  opaque. 
For  six  months  the  scar  did  not  change, 
and  then  it  began  to  grow.  At  two  years 
it  looked  like  a  large  staphyloma,  but 
when  examined  under  annisthesia  was 
found  to  be  a  large  tumor.  On  removal 
it  was  found   almost  eight  millimetres 


CORN-ERGOT  AND  CORN-SILK. 


COTTON-PLANT. 


339 


thick.  A  microscopical  examination 
showed  it  to  be  chiefly  keloid.  Two 
similar  cases  had  been  previously  re- 
ported by  Simon  and  Szokalski.  C.  D. 
Wcstcott  (Annals  of  Ophthal.,  p.  472, 
'97). 

Edward  Jackson, 

Denver. 

CORN-ERGOT    AND    CORN-SILK.— 

The  Indian  com  or  maize  {Zea  mays) 
yields  two  medicinal  substances:  one 
when  the  plant  is  diseased  with  smut, 
the  other  only  when  in  a  healthy  con- 
dition. 

Ustilago  maydis  is  a  fungus  growth: 
the  ergot  of  corn,  in  fact.  It  occurs  in 
globose  masses,  irregular,  three  to  six 
inches  thick,  made  up  of  nodular  and 
globular,  brownish-black  spores  inclosed 
in  a  blackish  membrane.  Its  taste  is 
unpleasant  and  its  odor  disagreeable. 
There  is  contained  a  volatile  alkali,  a 
fixed  oil,  and  principle  analogous  to 
sclerotic  acid. 

Stigmata  maydis,  or  "corn-silk,"  is  the 
green  pistils  of  maize-plant:  a  cereal 
that,  though  indigenous  to  North  Amer- 
ica, is  now  well  known  in  all  quarters  of 
the  civilized  globe.  The  pistils  are  of 
value  only  after  they  have  shed  their 
pollen. 

Preparations  and  Doses. — Corn-ergot, 
powdered,  10  to  GO  grains. 

Corn-ergot,  fluid  extract,  10  to  60 
minims. 

Corn-silk,  fluid  extract,  1  to  2  drachms. 

Corn-silk,  infusion  (1  to  S),  ad  libitum. 

Corn-silk,  syrup,  1  to  4  drachms. 

Corn-silk,  wine,  30  to  60  minims. 

Physiological  Action. — The  action  of 
corn-ergot  appears  to  be  relatively  the 
same  as  that  of  ergot  of  rye,  except  that 
the  contractions  induced  by  the  former 
are  regularly  intermittent,  and  those 
provoked  by  the  latter  are  tonic.  Corn- 
ergot  by  many  is  held  to  be  quite  as 


efficient  and  more  uniform  than  its  rye 
congener. 

Corn-silk  augments  the  secreting 
power  of  the  kidney,  and  is  likewise 
tonic  to  the  secretory  membrane;  thus 
it  is  both  diuretic  and  demulcent,  and 
perhaps  possessed  of  some  antilithic 
power.  Its  diuretic  action,  if  given  in 
full  doses,  is  both  mild,  certain,  and 
rapid,  whereby  a  debilitated  kidney  is  not 
only  relieved,  but  also  an  overburdened 
circulation:  the  pulse  becomes  more 
regular  and  the  arterial  tension  stronger. 
It  has  no  disturbing  effect  upon  any 
organ;  hence  its  tolerance  is  complete; 
and  it  can  be  taken  for  weeks  without 
inconvenience  of  any  kind.  Some 
French  authors  assume  it  to  be  locally 
anodyne  or  anaesthetic,  and  to  possess  a 
peculiar  elective  action  on  the  tissues 
of  the  ureter  and  bladder.  It  certainly 
is,  in  some  degree,  both  antiseptic  and 
antilithic. 

Therapeutics. — The  therapeutic  prop- 
erties of  ustilago  maydis  may  be  said  to 
be  those  of  ergot,  but  to  a  milder  degree. 
The  claim  has  been  made  that,  employed 
subcutaneously,  corn-smut  is  superior 
to  that  of  rye  in  the  treatment  of  uter- 
ine fil)roids,  but  this  lacks  confirmation. 

Genito-Ueinabt  Maladies. — Corn- 
silk  is  serviceable  in  all  inflammatory 
conditions  of  the  genito-urinary  appa- 
ratus, acute  or  chronic,  idiopathic  or 
traumatic.  It  is  especially  valuable 
where  intravesical  decomposition  of 
urine  has  given  rise  to  irritation;  and  it 
may  with  advantage  be  combined  with 
other  antilithics  in  the  treatment  of 
gravel,  etc. 

CORYZA,  ACUTE.  See  X.vs.vl  Cavi- 
ties. 

COTTON-PLANT.— Gossy/Jium  lierha- 
ceiim  is  a  plant  indigenous  to  the  trop- 


340 


COTTOX-PLAXi.    PHYSIOLOGICAL  ACTION.    THERAPEUTICS. 


ical  and  subtropical  regions  of  Asia 
and  Africa,  and  that  by  transplanta- 
tion has  become  a  native  of  the  west- 
ern hemisphere.  It  has  long,  petio- 
late,  palmate,  three-  or  five-  lobed 
leaves  of  a  green  or  dark-green  color; 
the  flowers  are  yellow.  The  bark  of  the 
root  occurs  in  thin,  flexible  bands  or 
quilled  pieces,  the  outer  surface  brownish 
yellow,  with  slight,  longitudinal  ridges 
or  meshes;  small,  black,  circular  dots; 
and  dull,  brownish-orange  patches  from 
the  abrasions  of  the  thin  cork;  inner 
surface  whitish,  of  a  silky  lustre,  and 
finely  striate;  bast-fibres  long,  tough, 
and  separable  into  papery  layers;  in- 
odorous; taste  slightly  acrid  and  as- 
tringent; seeds  oblong  or  ovate,  pointed 
at  one  end  and  covered  with  silvery- 
white  hairs. 

Preparations  and  Doses. — Cotton-root 
abstract,  3  to  15  grains. 

Cotton-root  extract,  solid,  2  to  10 
grains. 

Cotton-root  extract,  fluid,  30  to  120 
minims. 

Cotton-root  decoction  (1  to  10),  4  to 
16  drachms. 

Cotton-root  bark,  powdered,  20  to  60 
grains. 

Cotton-root  tincture  (1  to  -i),  1  to  4 
drachms. 

Cotton-seed  extract,  solid,  5  to  15 
grains. 

Cotton-seed  oil,  2  to  16  drachms  or 
more. 

Cotton-leaves,  tincture  (exprosseil 
juice  of  fresh  leaves,  1;  proof-spirit,  8), 
10  to  60  minims. 

Gossypin  (concentration),  1  to  5 
grains. 

Physiologfical  Action.  —  Cotton-root 
bark  is  ommenagogic,  oxytocic,  ecbolic, 
and  dooljstnient.  Its  action  is  prac- 
tically identical  with  that  of  ergot.  It 
is  safer   than   the   latter,   and    oporatos 


without  pain,  but  is  not  so  active,  espe- 
cially during  parturition.  It  also  re- 
quires to  be  given  in  larger  doses,  and 
may  be  exhibited  with  impunity  even  in 
the  first  stage  of  labor.  A  decoction  of 
the  fresh  root  is  more  active  than  either 
the  tincture  or  fluid  extract. 

The  juice  of  the  fresh  leaves  seems  to 
exert  a  tonic  alterative  action  on  the  in- 
testinal tract,  very  like  that  of  coto  and 
paracoto,  biit  less  pronounced. 

Cotton-seed  oil  is  a  succedaneum  for 
olive-oil;  it  is  bland  and  nutritious,  also 
slightly  expectorant,  markedly  galaeta- 
gogic  and  aphrodisiac.  An  extract 
made  from  cotton-seed  exhibits  these 
properties  in  greater  or  less  degree. 

Therapeutics, — The  therapeutic  indi- 
cations are  the  same  as  for  ergot  as  re- 
gards preparations  of  the  root.  The  fresh 
leaves  are  employed  internally  in  dysen- 
tery and  diarrhccas,  externally  to  inflamed 
joints,  the  breasts  of  nursing  women  to 
promote  the  secretion  of  milk,  and  to 
boils  and  abscesses  to  hasten  their  mat- 
uration. Cotton-seed  oil  finds  its  chief 
use  in  the  preparation  of  liniments. 

Parturition.  —  Cotton-root  bark  is 
mild  and  certain  in  action,  and  does 
not  produce  the  well-known,  rapid  con- 
vulsive action  of  ergot;  but,  on  the  con- 
trary, seems  to  greatly  stimulate  the 
uterus  to  normal  function.  It  acts  not 
alone  upon  the  uterine  muscles,  but 
also  upon  the  secretory  function. 

Gossypin  represents  the  emmcnagogic 
and  parturient  principle  of  cotton-root 
bark;  but,  unfortunately,  as  generally 
found  in  sliops,  owing  to  improper 
methods  of  manufacture,  is  seldom  to  be 
relied  upon. 

COW-POX.    Sec  Vaccinia. 

COXALGIA.     See  Hip-.ioint. 


CREASOTE.     PKEPARATIOXS  AND  DOSES. 


341 


COXITIS.     See  Hip-joixt. 

CEEASOTE. — Commercial  ereasote  is 
obtained  during  the  dry  distillation  of 
wood-tar,  or  from  crude  pyroligneous 
acid.  Medicinal  ereasote  is,  or  should 
be,  obtained  from  the  distillation  of  the 
tar  of  the  beech  {Fagus  sijlvatica).  The 
substance  is  exceedingly  complex,  being 
a  mixture  of  phenols,  chiefly  guaiacol  and 
cresol. 

Pure  ereasote  is  a  colorless,  oleaginous 
liquid  of  burning  taste  and  possessed  of 
a  disagreeable  penetrating,  smoky  odor 
that  is  most  characteristic.  Its  specific 
gravity  is  1.080,  but  much  of  that  sold 
as  pure  ereasote  will  be  found  to  vary 
from  1.035  to  1.085.  "With  age  it  ac- 
quires a  yellowish  hue,  and  if  continu- 
ously exposed  to  light  and  air  it  becomes 
of  a  deep-reddish  brown,  when  it  is  unfit 
for  medicinal  use.  It  is  but  sparingly 
miscible  ivith  water,  perhaps  1  to  130  up 
to  150,  but  is  soluble  in  all  proportions 
in  alcohol,  ether,  petroleum-spirit,  and 
glacial  acetic  acid.  It  is  often  substi- 
tuted for  by  crude  phenol,  to  which  it  is 
intimately  related,  both  chemically  and 
therapeutically.  The  fraud  may  be  de- 
tected by  the  simple  fact  that  the  latter 
is  soluble  in  glycerin,  while  ereasote  is 
not.  Again,  ereasote  does  precipitate  ni- 
trocellulose from  collodion,  and  gives  a 
green  reaction  with  a  weak  alcoholic  so- 
lution of  ferric  chloride;  phenol  gela- 
tinizes collodion  and,  with  the  iron  test, 
yields  a  bro;vn  reaction. 

Creasote  is  incompatible  with  strong 
mineral  acids,  and  reduces  some  of  the 
metallic  salts, — silver  nitrate,  for  in- 
stance. "With  silver  oxide,  explosion  and 
deflagration  result. 

Preparations  and  Doses.  —  Creasote 
(pure  beech-wood),  1  to  3  minims. 

Creasote  benzoate,  topical  use  only. 

Creasote  carbonate  (cresalol),  5  to  20 


Creasote  -  calcium  chlorohydrophos- 
phate,  3  to  8  grains  in  emulsion. 

Creasote  codliver-oil  (creasote,  15;  cod- 
liver-oil,  1000  parts),  1  to  4  drachms. 

Creasote  elixir  (creasote,  15;  rum, 
1000  parts),  1  to  4  drachms. 

Creasote  ointment,  simple  (creasote,  1; 
simple  cerate  or  other  fat  base,  8  parts). 

Creasote  ointment,  forlior:  used  for 
psoriasis  and  skin  diseases  of  like  char- 
acter only  (creasote,  60  grains;  )'ellow 
wa.x,  30  grains). 

Creasote  oleate  (oleocreasote),  20  to 
120  minims). 

Creasote  pills  (creasote  and  curd-soap, 
of  each,  120  grains;  make  2-grain  pills), 
1  to  3. 

Creasote  valerianate,  2  to  10  minims. 

Creasote-water  (creasote,  10;  distilled 
or  flavored  water,  990  parts),  1  to  4 
drachms. 

Creasol,  5  to  10  grains. 

Cresol,  external  use  solely. 

Creasol  iodide  (losophan),  external  use. 

Cresol-salicylate  (cresalol),  2  to  10 
grains. 

Cresoticacid,  disinfectant  only. 

Guaiacol  (liquid),  2  to  5  minims.  See 
Guaiacol. 

Guaiacol  benzoate  (benzosal;  benzoyl- 
guaiacol),  4  to  10  grains. 

Guaiacol  biniodide  (deuto-iodide),  1  to 
3  grains. 

Guaiacol-carbonate,  3  to  8  grains. 

Guaiacol-phosphate,  2  to  8  grains. 

Guaiacol-salol,  5  to  15  grains. 

Cresol,  meta-,  ortho-,  para-,  are  disin- 
fectants only. 

Paracroasotate  of  sodium,  1  to  15 
grains.    See  Sodium. 

Paracreasotic  (creasotinic)  acid,  10  to 
40  grains. 

Creasote  carhonaie,  or  cresolal,  is  a 
light-brown,  viscous  liquid,  almost  odor- 
less and  tasteless,  insoluble  in  water,  but 
soluble  in  oils;    it  contains  carbonates, 


342 


CKEASOTE.    PKEPARATIOXS  AND  DOSES 


guaiacol  and  cresol,  and  is  emplo3-ed  as 
a  substitute  for  creasote  proper.  It  is 
generally  stated  that  it  may  be  adminis- 
tered in  large  doses  for  a  lengthened 
period  ■srithout  untoward  result — that  it 
■vrill  not  in  any  way  disturb  the  economy, 
no  matter  what  the  amount  ingested; 
but  this  must  be  taken  cum  grana,  since 
it  is  based  solely  upon  the  dicta  of  inter- 
ested manufacturers  and  purvej'ors.  Be- 
sides, it  is  contrary  to  the  rules  of  evi- 
dence. 

Creasote-caJcium  chloroliydrophos pliate 
forms  a  white,  syrupy  mass,  but  presents 
no  advantages  over  creasote. 

Creasote  oleate,  or  oleocreasote,  also 
known  as  creasote-oleic  etlier,  is  obtained 
as  a  yellowish,  oily  liquid  of  a  specific 
gravity  of  0.950  at  59°  F.,  soluble  in 
ether,  chloroform,  and  benzene;  conse- 
quently it  can  only  be  administered  in 
emulsion. 

Creasote  valerianate  possesses  about  the 
same  value — at  higher  market-price — as 
creasote  carbonate,  but  is  supposed  to 
combine  also  the  effect  of  valerianic  acid, 
though  this  must  necessarily  be  uni- 
versal. 

Creasol  is  obtained  by  heating  beech- 
wood  creasote  with  tannic  acid  and  phos- 
phorus oxychloride.  It  is  a  dark-brown, 
very  hygroscopic  powder,  with  creasote 
odor  and  taste,  soluble  in  water,  alcohol, 
glycerin,  and  acetone;  and  insoluble  in 
ether.  It  is  held  to  be  astringent  and 
antiseptic. 

Cresol,  which  is  merely  an  antiseptic 
for  external  use,  di  iters  from  creasol  in 
that  it  is  a  yellow,  aromatic  liquid  pos- 
seesed  of  a  vanilla-like  odor. 

Cresalol,  paracreasalol,  or  paracrcsylic 
ether  of  salicylic  acid,  is  a  condensation 
of  salicylic  acid  with  paracrcsol,  whereby 
is  obtained  a  whitish,  crystalline  powder 
or  white  needles.  It  is  insoluble  in  water, 
but  freely  soluble  in  alcohol  and  ether. 


and  melts  at  about  39°  or  40°  F.  It  was 
introduced  as  a  substitute  for  salol,  but 
seems  not  to  have  received  any  great  con- 
fidence on  tlae  part  of  the  medical  pro- 
fession. 

For  "guaiacol"  see  Guaiacol,  vol.  iii. 

Creasotic,  cresotic,  or  pxiracresotic  acid 
— the  paracresol  of  French  authors — is 
a  homologue  of  salicylic  acid,  and  is  ob- 
tained in  long,  white,  prismatic  needles 
that  are  soluble  in  alcohol,  ether,  and 
chloroform.  In  minute  doses  it  is 
employed  as  an  antiseptic,  in  larger 
doses  as  an  antipyretic.  The  maxi- 
mum dose  during  twenty-four  hours  is 
60  gi'ains. 

Creasotinic  acid,  also  known  as  oxy- 
tolutic  or  homosalicylic  acid,  is  the  same 
as  the  foregoing;  is  also  obtained  as  an 
ortho-,  meta-,  or  para-  modification; 
hence  is  frequently  designated  in  the 
plural  as  "creasotic  acids."  The  para 
compound  only  finds  place  in  medicine, 
but  its  place  for  the  most  part  is  usurped 
by  its  sodium  salt. 

Creasote  is  largely  administered  in 
pillular  form,  which,  however,  is  ob- 
jectionable for  two  reasons:  First,  no 
suitable  excipient  is  known.  Second, 
creasote  pills  are  variable  in  strength 
and  by  no  means  stable,  besides  being 
nauseous. 

E.\amination  of  nine  commercial  sam- 
ples of  creasote  pills  made,  employing 
one  hundred  of  each  sample.  The  varia- 
tions were  as  follow: — 

Amount  of  creasote 

claimed.  present. 

1 5.00  4.92 

ir 2..'50  2.30 

HI 10.00  9.00 

IV 5.00  4.70 

V 5.00  1.05 

VI 5.00  2.25 

VII 5.00  3.14 

VIII 5.00  4„30 

IX 5.00  4.70 

IBcckurts  (Apotli.  Zeit,  '90;  Med.  Age, 
Nov.  25,  '90). 


CREASOTE.    HYPODERMIC  USE.    PHYSIOLOGICAL  ACTIOX. 


343 


In  prescribing  creasote  it  must  be 
borne  in  mind  that  the  ordinary  com- 
mercial article  is  derived  from  pine,  and 
unfit  to  be  employed  medicinally,  except, 
perhaps,  topically.  Medicinal  creasote  is 
always  understood  to  be  the  beech-wood 
product. 

Undoubtedly  the  best  method  of  ad- 
ministration is  in  some  fluid—  in  cod- 
liver-oil,  in  emulsion,  in  elixir,  or  as  com- 
bination of  the  elixir  and  codliver-oil. 

An  emulsion  may  be  prepared  by  mak- 
ing two  solutions — one  equal  parts  of 
alcohol  and  creasote,  the  other  equal 
parts  of  water  and  saccharate  of  casein 
—and  shaking  together.  This  should 
then  be  diluted  with  water,  in  the  pro- 
portion of  1  quart  to  10  drachms  of  the 
emulsion.  The  dose  is  1  drachm  mixed 
with  milk  or  from  3  to  4  ounces  admin- 
istered by  enema.  Lfgcr  (L'Union 
Pharm.,  July  1.5,  '93). 

A  palatable  mixture  is  the  following: 
Creasote  and  glacial  acetic  acid,  of  each, 
15  minims;  spirit  of  juniper,  30  minims; 
syrup,     1     ounce;     distilled     water,     15 
ounces.     The    dose    is    1  to    2    ounces. 
Whitla      ("Pharm.,     Mat.      Med.,     and 
Thcrap.,"  '92). 
It  has  been  proposed  to  administer 
creasote  in  "enteric  coated"  pill, — i.e.,  a 
pill  that  will  only  dissolve  in  intestinal 
fluids;   but  such  pill  coating  is  theoret- 
ical only,  and  all  those  that  have  been 
exploited  have  proved  failures.     They 
are  based  upon  the  assumption  that  the 
normal  intestinal  secretions  are  invari- 
ably acid,  which  is  far  from  being  true; 
indeed,  the  opposite  is  the  fact. 

Hypodermic  Use. — Formerly  creasote 
was  employed  subcutaneously  only  when 
added  to  other  remedies  to  preserve  the 
solution.  An  old  formula  was  10  grains 
of  morphine  in  60  minims  of  creasote,  of 
which  the  dose  was  6  minims,  but  its 
injection  was  extremely  painful  and  pro- 
duced an  elevation  of  the  skin  resulting 
in  a  yellow  pustule  which,  though  it  sub- 
sided on  the  second  day,  was  succeeded 


by  sloughing,  redness,  infiltration,  and 
thickening.  Only  sciatica  could  justify 
this  measure.  But,  when  the  drug  began 
to  be  employed  for  phthisis,  the  follow- 
ing found  favor  among  French  practi- 
tioners:— 

^  Dried  pepsin,  20  grains. 
Morphine  muriate,  1  grain. 
Beech-creasote,  6  minims. 
Glycerin  (neutral),  154  minims. 
Alcohol,  20  minims. 
Water,  enough  to  make  224  min- 
ims. 

Dose,  IG  minims,  five  or  six  times 
daily,  injected  deep  into  the  muscular 
substance.  The  morphine  is  often  left 
out,  its  sole  purpose  being  the  obtunding 
of  the  pain  that  supervenes  after  the 
operation.  On  the  whole,  however,  crea- 
sote hypodermically  possesses  no  advan- 
tage over  the  oral  administration. 

Physiological  Action. — Topically,  cre- 
asote is  caustic,  antipruritic,  analgesic, 
astringent,  and  markedly  antiseptic  and 
germicide.  Taken  internally,  in  small 
doses  it  is  expectorant  and  a  cardiac  and 
nerve-stimulant;  besides,  it  is  cooling 
and  sedative  to  the  stomach,  from  which 
it  is  readily  absorbed  into  the  circulation 
and  then  diffused  with  great  celerity;  it 
is  styptic,  increasing  the  coagulability  of 
the  blood.  Larger  doses  depress  the 
heart  and  nervous  system,  but  accelerate 
respiration  and  render  it  full,  with  per- 
haps a  secondary  result  which  entirely 
reverses  the  order;  it  stimulates  the  vagi 
both  at  the  periphery  and  centre.  It  is 
eliminated  chiefly  by  the  kidneys  and 
lungs.  Its  beneficial  effects  cannot  be 
attributed  to  any  antibacillary  action, 
since  it  does  not  diminish  the  number  of 
the  bacilli  of  tuberculosis  nor  even  di- 
minish their  virulence. 

Creasote  is  eliminated  by  the  kidney* 
no  matter  how  administered,  and  the 
largest  amount  thrown  out  is  during  the 


34^ 


CKEASOTE.    POISONING. 


first  twelve  hours  after  administration. 
The  elimination  br  the  limgs  is  com- 
paratively insignificant.  The  guaiacol 
element  appears  to  be  most  rapidly  elim- 
inated. Imbert  (Nouv.  Montpellier  MSd., 
'92;  Ther.  Gaz.,  Mar.,  '92). 

The  favorable  action  of  creasote  is  due 
to  (a)  bactericidal  actio"n  on  the  microbes 
which  accompany  the  bacillus  of  Koch; 
(6)  to  its  stimulating  action  on  nutri- 
tion, so  that  phagocytes  which  prey 
upon  the  tubercle  bacilli  are  increased 
in  number;  and  (c)  to  its  chemical  ac- 
tion on  the  toxins  excreted  by  bacilli. 
Savine  (Academy  of  Medicine,  July,  '9S). 

Poisoning  by  Creasote. — Wlaen  toxic 
quantities  are  ingested,  the  heart  and  cir- 
culation are  powerfully  depressed,  the 
temperature  is  lowered  several  degrees, 
the  pupils  are  minutely  contracted,  and 
respiration  is  paralyzed.  This  is  also  the 
case  with  the  vasomotor  centre  of  the 
medulla;  there  is  first  vertigo,  later 
stupor.  Owing  to  stimulation  of  the  an- 
terior comu  of  the  cord,  muscular  trem- 
blings and  even  convulsions  may  super- 
vene. 

Some  persons  seem  very  sensitive  to 
the  action  of  creasote,  while  others  ap- 
pear to  tolerate  it  in  enormous  doses  ; 
hence  the  problem  of  elimination  should 
be  taken  into  account  on  all  occasions 
where  the  drug  is  prescribed. 

Two  cases  of  pulmonary  tuberculosis 
treated  by  rectal  injections  of  creasote 
30  minims  daily.  The  urine  soon  became 
black,  though  clear  when  first  passed, 
and  resembled  that  excreted  in  carbolic- 
acid  poisoning.  Even  after  the  substitu- 
tion of  guaiacol  for  creasote,  one  case  con- 
tinued  to  pass  urine  that  became  black. 
Nimier  (L'Union  MCd.,  Aug.  31,  '95). 

Case  of  a  man,  aged  35,  sufVering  from 
phthisis  pulmonalis,  who  commenced  to 
use  creasote  in  doses  of  1  minim  thrice 
daily,  and  rapidly  increased  the  same 
until  lie  was  ingesting  exactly  340 
minims  every  twenty-four  lioiirs.  Dur- 
ing two  and  one-half  niontlis  lie  con- 
tinued to  take  3  and  4  fluidrachms 
daily,  and  tlicn  he  reduced  to  140  minims, 


which  he  still  continues.  He  has  never 
experienced  any  ill  eft'ects.  Graham 
(Brit.  Med.  Jour.,  Jan.   15,  '9S). 

Eesult  of  six  experiments  on  dogs: 
1.  Creasote,  1  to  G25  body-weight,  caused 
death  in  twenty  minutes.  Tlie  necropsy 
showed  acute  gastro-enteritis  (stomach 
strongly  corroded  and  small  intestines 
markedly  inflamed),  and  pulmonary 
(Edema  from  cardiac  paralysis.  2.  Crea- 
sote carbonate,  I  to  3165  body-weight, 
did  not  give  rise  to  the  slightest  disturb- 
ance. 3.  The  same  dog  on  the  following 
day  received  creasote  carbonate,  I  to  600 
body-weight,  but  presented  no  abnormal 
symptoms  beyond  hebetude.  4.  A  dose 
of  the  same,  I  to  500  body-weight,  gave 
no  results.  5.  Guaiacol,  about  1  to  1000 
body-weight,  gave  rise  to  uncertainty 
in  hind-legs,  falling,  vomiting,  trembling, 
especially  of  the  limbs,  and  sluggish 
pupils.  The  vomiting  continued,  with 
noisy  respiration,  watery  discharge  from 
the  mouth,  and  later  subnormal  tempera- 
ture, slow  respiration,  and  slow  pulse 
were  observed.  Death  followed  in  about 
seven  hours  from  the  administration  of 
the  drug.  The  necropsy  showed  acute 
gastro-enteritis  (marked  inflammation  of 
the  gastric  and  upper  portion  of  the 
small  intestine  and  swelling  of  the  re- 
mainder) and  pulmonary  oedema  from 
cardiac  paralysis.  6.  Guaiacol  carbon- 
ate, 1  to  500  body-weight,  caused  no 
results.  7.  The  same,  1  to  380  body- 
weight,  also  produced  no  result.  In  con- 
clusion it  can  be  stated  that  both  crea- 
sote and  guaiacol  in  large  doses  are 
poisonous,  and  cause  death  through  their 
corrosive  action,  and,  per  contra,  crea- 
sote and  guaiacol  carbonates,  even  in 
large  doses,  have  no  influence  upon  the 
system.  W.  Hesse  (Deut.  med.  Woch., 
No.  5,  '98). 
Stertorous  breathing;  cold,  clammy 
skin;  pinched  face,  anxious  expression, 
abolition  of  reflexes;  weak,  thready,  and 
often  imperceptible  pulse;  feeble  respira- 
tion, and,  above  all,  the  odor  of  the  drug 
are  the  prominent  symptoms  of  poison- 
ing. Death  occurs  from  failure  of  respi- 
ration, and  the  heart  is  arrested  in  di- 
astole. 


CREASOTE.    DERIVATIVES.    THERAPEUTICS. 


345 


According   to    tlie    Bulletin    of    Phar- 
macy for  December,  much  of  the  com- 
mercial article  sold  as  "crcasote"  is  not 
the  creasote  intended  by  the  "Pharma- 
copoeia," made  from  beech-wood,  but  is 
instead  liquefied  carbolic  acid  made  from 
coal-tar:   a  distinctly  poisonous  article 
not  to  be  administered  for  the  purpose 
for  which  true  creasote  is  indicated.    In 
prescribing     this     drug     the     physician 
should  be  careful  to  specify  the  official 
article,  unless  he  is  satisfied  that  the 
prescription  will  be  filled  by  a  pharma- 
cist who  submits  all  of  the  drugs  he  dis- 
penses   to    pharmacopoeial    tests.      Edi- 
torial (Penna.  Med.  Jour.,  Dec,  1902). 
jyeatment  of  Poisoning. — If  seen  in 
time,  the  stomach  should  at  once  be 
washed    out.      Epsom    salt,    demulcent 
drinks,   heat   to   body  and   limbs,   and 
atropine  and  strychnine  hypodermically 
are  indicated;  coffee,  digitalis,  and  opium 
for  the   relief  of  pain,   are   often   de- 
manded.    Soluble  sulphates  have  been 
credited  with  powers  as  antidotes. 

Derivatives. — The  creasote  prepara- 
tions and  derivatives  differ  little  from 
the  drug  itself  as  to  physiological  action. 
Most  have  been  exploited  on  the  score  of 
greater  palatability  or  as  being  less  nox- 
ious, but  the  evidence  as  regards  the  lat- 
ter rests  upon  a  very  slender  foundation. 
Creasol  is  more  astringent,  and  crcasote 
carbonate  more  palatable. 

Creasote  carbonate  is  better  borne  than 
ordinary  beech-wood  creasote.  It  has, 
in  many  cases,  a  tendency  to  diminish 
secretion;  it  seems  to  have  no  influence 
upon  peristalsis.  Occasionally  it  excites 
fluid  stools,  but  these  vanish  in  one  or 
two  days  and  normal  evacuations  suc- 
ceed ;  occasionally  it  appears  to  induce 
costiveness.  There  is  no  unpleasant  ac- 
tion on  the  stomach:  eructations  and 
vomiting  are  rare,  and  only  appear  after 
large  doses  have  been  ingested,  and  even 
then  rapidly  disappear  without  with- 
drawal of  the  rcmcd.v.  It  increases  ap- 
petite, diminishes  and  deodorizes  the  se- 
cretion of  lung  and  kidney,  and  exerts 
generally  a  favorable  effect  upon  nutri- 
tion.   Reiner  (Thcr.  Woch.,  Jan.,  '9G). 


Paracreasoiic  or  creasotinic  acid  has 
been  employed  along  the  same  lines  as 
creasote  carbonate. 

No  marked  effect  is  produced  upon  the 
healthy  human  organism  by  doses  of  40 
to   GO  grains,   with   the   exception   of  a 
feeling   of  great   fullness   of  the   blood- 
vessels of  the  skin,  a  light  pulsation  of 
the  arteries,  and  a  moderate  perspiration. 
Xo   influence  is  exercised  on  the  digestive 
functions.     In  some  cases,  however,  the 
drug  induced  collapse  and  erythematous 
eruption.     As  a  rule,  children  bear  the 
drug  well.    Thus,  in  a  boy,  12  years  old, 
15  grains  were  given  every  five  hours, 
and  even  larger  doses  produced  no  after- 
effects.   The  temperature  was  reduced  2 
degrees.     Demme    (Wiener   mod.   Blatt., 
Apr.  15,  '90). 
Cresotic  {not  Creasolic)  Acids — Para- 
and  OrtliO: — A  proposal  to  utilize  these 
chemical  compounds  as  remedies  for  in- 
ternal administration,  led  to  a  study  of 
their  effects.     These  seem  to  centralize 
upon  the  spinal  cord. 

The  fatal  dose  of  paracresotic  acid  is 
about  3  grains  per  pound-weight  of  an- 
imal ;  double  this  killed  a  rabbit  of  2  V, 
pounds  in  three  hours,  and  12  grains,  in 
the  same  time,  one  a  pound  heavier.  One 
grain  of  the  ortho-acid  per  pound  of  body- 
weight  is  suflicient  to  cause  death  in 
from  twelve  to  thirty-six  hours,  this 
being  preceded  by  symptoms  of  paralysis, 
especially  of  forelimbs.  A  combination 
of  both  drugs  resulted  in  increased  poi- 
sonous properties.  Chartcris  (Brit.  Med. 
Jour.,  Mar.  2S,  '01). 

Therapeutics.  —  Gastro-Ixtestinal 
Disorders. — In  vomiting,  gastrodjTiia, 
nausea,  etc.,  creasote  is  a  remedy  of  great 
power  and  an  excellent  rival  of  hydro- 
cyanic acid.  Even  in  the  vomiting  at- 
tendant on  malignant  disease  of  the 
stomach,  duodenum,  liver,  or  pancreas, 
it  is  often  most  effective,  though  the  re- 
lief afforded  is  necessarily  but  temporary. 
In  the  diarrha?as  of  children  and  infants, 
especially  those  peculiar  to  the  heated 
term,  it  is  of  great  utility,  and  not  infre- 
quently it  serves  a  most  excellent  purpose 


346 


CREASOTE.     THERAPEUTICS. 


in  the  management  of  tropical  diarrhoea 
and  dysenteries. 

HEMORRHAGES. — Here  the  drug  has 
been  employed  ■svith  great  advantage, 
both  topically  and  internally.  Few  rem- 
edies are  so  valuable  in  hemoptysis,  in 
hjematemesis,  hematuria;  it  is  invalu- 
able in  the  washing  out  of  bladder,  in- 
testinal hemorrhages  of  continued  fever, 
etc.  In  superficial  bleedings  from 
wounds,  leech-bites,  after  the  extraction 
of  teeth,  the  topical  application  is  al- 
most magical  in  results;  and  the  late 
McCormack,  by  its  aid,  once  arrested 
haemorrhage  from  the  carotid  artery. 
Though  there  is  no  definite  record  of  its 
use  in  cases  of  hemophilia,  such  would 
seem  to  have  definite  basis,  though  from 
a  palliative  rather  than  remedial  stand- 
point. 

Diabetes, — It  has  been  observed 
when  this  drug  is  administered  in  small 
doses,  thrice  daily,  in  diabetes,  gradually 
increasing  by  1  drop  every  alternate  day 
until  the  point  of  toleration  is  reached, 
that  it  has  a  very  beneficial  action  on 
diabetes;  but  aperients  should  be  fre- 
quently employed  in  order  to  assist  elim- 
ination by  the  bowels.  Usually  the  urine 
is  much  improved  in  quantity  and  char- 
acter, and  there  is  frequent  micturition. 

Creasote,  when  administered  inter- 
nally, is  of  considerable  value  in  the 
treatment  of  diabetes  mellitus.  In  two 
cases  4  drops  were  given  daily,  and  grad- 
ually increased  10  minima,  under  which 
the  sugar  gradually  disappeared  from  the 
urine,  and  even  a  return  to  starchy  food 
did  not  cause  any  reappearance  of  sac- 
charine matter.  Valentin!  (Les  Nouv. 
Remedes,  Mar.  8,  '91). 

Veneheai,  Diseases. — In  gonorrhoea, 
blennorrhoja,  gleet,  etc.,  especially  the 
chronic  stage  of  the  former,  creasote  is 
often  of  greater  benefit  than  cubebs,  co- 
paiba, santal-wood  oil,  and  the  like,  and 
it  may  bo  employed  both  by  the  mouth 


and  by  urethral  injection.  It  is  especially 
available  in  gonorrhcea  of  the  female;  in 
leucorrhceas,  etc.,  and  as  a  wash  and 
gargle  to  syphilitic  lesions  of  all  forms, 
especially  specific  ozena. 

Fifty  cases  of  gonorrhoea  in  the  male 
that  were  successfully  treated  with  in- 
jections of  emulsion  of  creasote,  2  to  10 
per  1000.  The  discharge  quickly  de- 
creased, became  mucoid,  and  then  ceased 
altogether.  The  patients  recovered  more 
rapidly  than  under  ordinary  methods 
and  without  a  single  complication  or  re- 
lapse. The  creasote  seems  to  exercise  an 
ansesthetic  action  on  urethral  mucous 
membrane.  Larska  (^led.  Oboz.,  '96; 
Med.  Age,  Jan.  25,  '97). 

Cystitis. — Inasmuch  as  creasote  and 
its  derivatives  when  administered  by  the 
stomach  tend  to  prevent  decomposition 
of  urine,  it  has  been  suggested  they  may 
prove  useful  in  cystitis,  enlarged  pros- 
tate, and  paralyzed  bladder. 

Septic  Diseases. — The  value  of  the 
drug  in  the  management  of  all  forms  of 
sepsis  cannot  be  too  highly  extolled.  It 
is  one  of  the  very  few  agents  that  make 
an  impression  on  glanders  in  the  human 
subject,  and  it  is  even  more  ellective  in 
anthrax,  puerperal  fever,  carbuncle,  etc., 
and  may  be  employed  both  internally 
and  topically. 

It  has  also  been  employed,  locally  and 
internally,  in  erysipelas,  including  the 
phlegmonous  form,  in  phlegmasia  dolens, 
and  puerperal  fever.  In  idiopathic  ery- 
sipelas it  should  be  applied  pure,  or  suf- 
ficiently strong  to  render  the  cuticle 
white  immediately  it  is  touched,  and  pen- 
ciled over  the  whole  of  the  infiamed  sur- 
face, even  beyond  it.  In  the  phleg- 
monous form  the  applications  should  be 
more  frequent,  and  compresses  soaked 
in  weak  alcohol  (in  which  a  little  creasote 
may  be  dissolved)  kept  constantly  ap- 
plied. 

Skin   Diseases. — Creasote   long   en- 


CREASOTE.    THERAPEUTICS. 


347 


joyed  considerable  celebrity  as  a  remedy 
for  lepra,  psoriasis,  impetigo,  acne,  pru- 
rigo senilis,  ephclis,  tinea  in  all  its  forms, 
sycosis,  and  scabies,  but  of  late  years  it 
has  been  little  employed,  owing,  in  part, 
to  its  disagreeable  odor  and  the  difficulty 
encountered  in  securing  a  pure  product, 
and  partly  to  the  fact  that  its  place  has 
been  usurped  by  carbolic  acid.  The 
stronger  creasote  ointment  (creasote,  1 
drachm;  yellow  wax,  30  grains)  is  more 
especially  intended  for  use  in  lepra,  pso- 
riasis, and  tinea  tricophytina,  but  should 
never  be  applied  to  the  face,  the  neck, 
the  abdomen,  or  the  flexor  surface  of 
the  limbs. 

Ulceeations. — Xon-specific  slough- 
ing and  phagedenic  ulcerations  are  often 
greatly  benefited  by  the  stronger  oint- 
ment of  creasote,  or  even  by  pure  crea- 
sote, locally  applied;  they  become  clean, 
and  long-standing  ones  heal  rapidly.  To 
indolent  and  mild  ulcers,  weak  solutions, 
or  the  elixir  may  be  applied;  the  same 
appears  efficacious  in  the  management  of 
bed-sores,  and  it  has  even  been  claimed 
that  sponging  with  a  1  to  80  lotion  will 
prevent  their  formation. 

As  stimulants,  antiseptics,  and  escha- 
rotics,  applications  of  creasote  are  often 
made  which  range  in  strength,  according 
to  the  severity  of  the  case  and  the  sensi- 
tiveness of  the  part,  from  1  drop  to  1 
ounce  of  water,  up  to  the  pure  drug. 
Thus  are  treated  a  large  number  of 
morbid  conditions,  among  them  indolent 
and  sloughing  ulcers,  fistulse,  gangrenous 
surfaces,  leucorrhcca,  puerperal  metritis, 
fretid  otorrhcoa,  diphtheria,  burns  with 
excessive  suppuration  and  redundant 
granulations,  and  chilblains,  and  to  wash 
out  the  pleura  in  cases  of  empyema. 

Ulcers  of  the  larynx,  whetlier  tuber- 
cular or  not,  may  be  treated  by  the  appli- 
cation of  creasote,  and  a  solution  con- 
taining 1  or  2  drops  of  creasote  to  1 


ounce  of  water  is  useful  as  a  stimulating 
and  disinfecting  gargle. 

TuiiORS  and  exceescexces  have  been 
treated  by  the  local  application  or  injec- 
tion of  creasote,  with  more  or  less  suc- 
cess, yet  there  are  so  many  remedies  of 
more  pleasant  character  that  the  method 
has  been  practically  abandoned. 

Pulmonary  Diseases. — It  is  in  dis- 
eases of  the  respiratory  tract  that  the 
remedy  has  gained  greatest  repute  in 
late  years.  Inasmuch  as  it  is  eliminated 
by  the  bronchial  mucous  membrane, 
which  it  stimulates,  it  is  an  expectorant 
of  great  value,  especially  so  if  there  be 
any  fcetor  of  the  secretion.  In  full  doses 
it  is  the  most  valuable  of  all  remedies  in 
chronic  basilar  cavities.  It  is  strongly 
recommended  in  pulmonary,  larjTigeal, 
and  abdominal  tuberculosis,  and  there  is 
little  doubt  that  it  is  one  of  the  best 
agents  yet  introduced  for  the  treatment 
of  ordinary  phthisis  and  of  bronchi- 
ectasis, bronchorrhoea,  broncho-pneu- 
monia, and  some  forms  of  bronchitis. 
The  greatest  drawback  to  the  use  of  the 
drug  is  the  inability  of  many  patients  to 
take  it  in  doses  sufficient,  either  as  to 
amount  or  to  their  continuance,  to  be  of 
benefit.  The  different  modes  of  adminis- 
tration that  have  been  advocated,  except 
that  by  the  mouth,  are  all  objectionable; 
the  rectum  is  even  more  intolerant  than 
the  stomach,  and  after  a  few  days  the 
patient  loses  control  of  the  bowel  and  is 
frequently  attacked  by  colic  and  diar- 
rhoea. With  subcutaneoiis  injections,  the 
risk  is  run  of  inducing  gangrene  or  ab- 
scess, and  the  pain  is  not  alone  consid- 
erable, but  often  excruciating.  Injection 
into  the  trachea,  which  has  been  sug- 
gested, has  not  as  yet  been  sufficiently 
tried  to  warrant  more  than  a  mention. 
The  subject  will  be  taken  up  exhaustively 
when  the  various  forms  of  pulmonary 
phthisis  are  studied. 


348 


CREASOTE.    THERAPEUTICS. 


Intratracheal  injections  of  creasoted 
oil  (1  to  20)  are  admirably  borne  by  the 
majority;  30  minims  may  be  employed 
twice  daily.  Xo  complications  are  pro- 
voked, and  the  patients  never  had 
htemoptysis,  fever,  stitch  in  side,  or  di- 
gestive trouble.  Experiments  showed  that 
the  oil  reached  the  alveoli,  and  stayed 
there  fifteen  days.  The  injections  should 
be  practiced  during  many  months,  and 
it  is  necessary  to  auscultate  the  patients 
frequently  and  make  them  take  a  posi- 
tion that  will  allow  the  oil  to  penetrate 
to  the  diseased  portions  of  the  lungs;  it 
is  often  possible  to  determine  whether 
the  oil  has  reached  the  part  by  the  pro- 
duction of  bubbling  rales.  Under  this 
treatment  the  majority  of  cases  improve, 
appetite  returns,  weight  is  increased,  and 
expectoration  is  diminished;  but  it  is 
those  in  the  first  or  second  stage  of 
tuberculosis  who  are  most  benefited.  Dor 
(Rev.  de  Med.,  Feb.,  '90). 

In  the  treatment  of  phthisis  creasote 
may  be  said  to  have  superseded  all  other 
remedies.  'When  used  in  the  earlier 
stages  of  the  disease,  along  with  other 
measures,  out-of-door  life,  proper  food, 
etc.,  it  is  undoubtedly  able  to  afford  cures. 

Of  93  phthisical  patients  treated  by 
creasote  54  were  benefited  and  25  ap- 
.  parently  cured.  Bouchard  (Archiv.  Clin, 
de  Bordeaux,  Mar.,  '89). 

By  the  hypodermic  use  of  a  10-per- 
cent, solution  of  creasote  in  oil  of  sweet 
almonds,  making  the  injection  into  the 
cellular  tissue  of  tlie  external  iliac  fossa, 
the  medicament  can  be  introduced  into 
the  circulation  without  any  derangement 
of  digestion.  At  least  two  injections, 
each  of  75  minims  of  the  solution,  should 
be  given  daily.  Perron  (Gaz.  lleb.  dea 
Scien,  Mfd.,  May  25,  '90). 

Subcutaneous  injections  of  creasoted 
oil  gives  excellent  results  in  the  treat- 
ment of  all  wasting  diseases,  pulmonary 
or  otherwise.  The  injections  are  followed 
by  local  and  general  clTccts,  but  never  of 
BcriouB  nat\ire;  absorption  is  more  or 
less  rapid,  and  no  abscess  produced.  The 
best  results  are  had  in  apyrctic  phthisis, 
witli  or  without  abundant  expectoration. 
Guerder  (.Jour,  de  Mfd.,  May  3,  '91). 


Creasote  diminishes  expectoration,  les- 
sening its  purulency  and  the  tendency  to 
haemorrhage.  Burney  Yeo  ("Man.  Prac. 
Treat.,"  vol.  ii,  '92). 

In  a  series  of  one  hundred  eases  it  was 
noted  that  its  chief  action  was  to  lessen 
cough  and  expectoration,  without  influ- 
encing the  progress  of  the  disease.  Osier 
(••Prac.  of  Med.," '92). 

It  certainly  exerts  a  curative  influ- 
ence on  the  tubercular  lesion  and,  be- 
sides lessening  expectoration,  purulency, 
and  the  tendency  to  night-sweats,  it 
seems  to  diminish  the  number  of  tuber- 
cular bacilli.  Jaccoud  (Bull.  Gen.  de 
IhOr.,  '92). 

Creasote  used  in  nearly  four  hundred 
cases,  including  not  only  the  pulmonary 
form,  but  tubercular  disease  of  the  peri- 
toneum, the  joints,  the  bones,  the  glands, 
and  the  larynx.  Great  care  is  demanded, 
both  as  to  the  method  of  administration 
and  the  quality  of  the  drug.  A  conven- 
ient way  of  prescribing  it  is  in  capsules 
containing  2  or  4  minims  of  creasote 
mixed  with  codliver-oil;  and  these  should 
always  be  given  immediately  after  eat- 
ing and  never  on  an  empty  stomach. 
After  several  days  complete  tolerance  is 
established,  and  within  four  or  five  days 
the  dose  can  be  gradually  increased,  until 
finally  the  stomach  improves  in  every 
way,  and  all  irritation  with  the  accom- 
panying indigestion  has  been  relieved. 
In  regard  to  the  method  of  increasing 
the  dose,  the  following  rule  will  be  found 
to  work  well :  Begin  with  2-minini  dosea 
three  times  a  day;  in  acute  cases  in- 
crease the  dose  by  2  minims  every  fourth 
day  until  12  minims  are  given  at  one 
time;  then  observe  the  results  of  the 
largest  dose  for  several  weeks,  and,  if  the 
improvement  is  not  satisfactory,  care- 
fully add  2  minims  more  every  eight  or 
nine  days  until  a  20-minim  dose  has  been 
reached;  then  persist  with  this  quantity 
until  the  symptoms  warrant  a  diminution 
of  the  amount.  The  highest  dose  has 
frequently  been  used  for  four  or  five 
months  at  a  time  before  decreasing  it, 
with  the  most  satisfactory  results.  The 
chronic  cases  do  not,  as  a  rule,  require 
BO  large  a  dose,  or  to  have  it  so  rapidly 
increased.  In  average  chronic  cases  the 
patients   use    12    minims   three   times   a 


CREASOTE.    THERAPEUTICS. 


349 


day,  beginning  with  2  minims,  increas- 
ing by  2  minims  every  six  days  to  8 
minims,  then  every  second  week  to  12 
minims,  according  to  the  effect.  During 
the  first  week  or  ten  days  there  are 
troublesome  eructations  of  gas  flavored 
with  creasote,  but  not  a  single  instance 
has  been  seen  where  this  did  not  entirely 
subside  after  the  creasote  had  corrected 
the  fermentation  caused  by  old  indiges- 
tion. Conway  (N.  Y.  Med.  Jour.,  June 
1,  '95). 

Before  giving  the  patient  with  phthisis 
creasote  he  should  be  placed  in  the  con- 
ditions favorable  to  his  recovery  by  sub- 
mitting liim  to  the  air-cure.  For  really 
successful  treatment  large  doses  of  crea- 
sote are  required;  the  greater  the  quan- 
tity of  the  medicament  which  the  pa- 
tient can  sustain,  the  more  chance  there 
is  for  recovery.  It  may  be  given  in  the 
mouth,  the  rectum,  the  trachea  (by 
means  of  injection),  and  the  skin.  The 
most  convenient  forms  in  which  to  ad- 
minister creasote  by  the  mouth  are  pills 
and  solution  in  codliver-oil,  and  in  either 
of  these  the  dose  may  be  as  much  as 
30  grains  or  even  more  per  day.  In 
many  cases,  however,  doses  of  not  more 
than  .3  grains  cause  indigestion,  and  a 
tuberculous  patient  should,  above  all 
else,  be  kept  free  from  disturbance  of  his 
digestive  functions.  The  rectum  is  less 
able  to  tolerate  the  remedy  than  the 
stomach,  and  after  a  very  few  days  the 
patient  loses  control  of  the  bowel  and 
is  frequently  attacked  by  colic  and  diar- 
rhoea. E.  Chauniicr  (Lancet,  Jan.  22, 
■98). 

When  tuberculosis  of  the  larynx  com- 
plicates the  pulmonary  trouble,  creasote 
should  be  employed  locally  as  well.  The 
fact  should  be  borne  in  mind,  however, 
that  the  benefit  observed  will  mainly  de- 
pend upon  the  internal  administration 
of  the  remedy,  though  the  local  applica- 
tions greatly  assist  the  curative  process. 

Creasote  is  quite  as  efficient  in  laryn- 
geal tuberculosis  as  it  is  in  the  pul- 
monary form,  but  should  be  used  both 
internally  and  topically.  For  the  latter 
an  oily  sohition  is  preferred,  such  as 


R  Beech-wood  creasote,  2  drachms. 

Oil  of  wintcrgreen,  2  drachms. 

Hj'drocarbon  oil,  1  drachm. 

Castor-oil,  3  drachms. 
The  oil  of  wintergieen  and  castor-oil 
should  first  be  mixed  together,  then  the 
hydrocarbon  oil  added,  and,  lastly,  the 
creasote.  Sterilizing  the  solution  by  dry 
heat  gives  it  a  much  clearer  appearance; 
besides  it  is  very  fluid  and  non-irritating, 
of  pleasant  odor  and  taste.  It  may  be 
used  as  a  spray,  or  applied  with  a 
laryngeal  applicator  or  as  a  submucous 
injection.  Tppical  application  alone  may 
be  relied  on  for  the  successful  relief  of 
the  symptoms  of  primary  tubercular  de- 
posits with  infiltration  and  hypertrophy 
of  the  mucous  membrane,  provided  the 
temperature  is  not  high  and  the  general 
condition  is  good.  If,  on  the  other  hand, 
the  evening  temperature  is  high  and  the 
case  seemingly  progressing  to  active  ul- 
ceration, a  few  submucous  injections 
sliould  be  used  as  adjuncts  to  local  treat- 
ment. The  cough,  laryngeal  soreness, 
and  moderate  dysphagia  of  primary  cases 
are  quickly  relieved  by  sprays  of  creasote, 
but  resolution  of  their  infiltrations  and 
hypertrophies  is  not  so  rapid.  In  several 
patients  laryngeal  distress  was  relieved 
after  a  few  applications,  but  the  infiltra- 
tion continued  for  montlis. 

The  interior  of  the  larynx  should  be 
thoroughly  cleansed  before  any  treat- 
ment is  undertaken.  Applications  may 
be  made  by  means  of  down  sprays,  of 
the  laryngeal  syringe,  or  by  absorbent 
cotton  on  an  applicator;  but  the  latter 
occasionally  produces  an  undesirable 
amount  of  coughing.  An  8-  or  10-per- 
cent, solution  of  cocaine  should  first  be 
carefully  applied  to  the  larynx,  and,  after 
it  has  had  time  to  produce  moderate 
anresthesia,  the  spray  of  creasote  (2 
drachms  to  the  ounce)  is  used.  After  the 
spray  the  pyriform  sinuses  may  be  filled 
with  creasote  solution,  and  also  some  of 
it  allowed  to  drop  into  the  trachea 
through  the  opening  of  a  gum-elastic 
tip  drawn  over  the  cannula  of  the  syr- 
inge. This  keeps  the  laryngeal  surfaces 
bathed  in  creasote  for  a  considerable 
period,  and  the  patient  should,  if  possible, 
be  kept  perfectly  quiet  and  not  allowed 
to  talk  or  swallow  for  half  an  hour  after- 


350 


CKEASOTE.    THERAPEUTICS. 


ward.  The  stronger  solution  of  creasote 
may  be  used  every  third  or  fourth  day 
and  the  weaker  ones  every  day  or  so, 
depending  entirely  on  the  amount  of 
stimulation  it  produces;  the  laryngeal 
membrane  becomes  very  red  and  consid- 
erably swelled  from  too-frequent  applica- 
tions. In  the  ulcerative  stages  of  laryn- 
geal tuberculosis  sprays  of  a  drachm  of 
creasote  to  the  ounce  may  be  used  daily 
with  advantage;  but  if  there  is  no  ulcer- 
ative process  a  personal  experience  of 
each  must  decide  the  frequency  of  the 
applications.  A  slight  burning  sensa- 
tion follows,  but  it  only  lasts  a  few  min- 
utes; and  the  disagreeable  taste  is  very 
effectually  covered  by  the  wintergreen- 
oil.  Where  there  is  ulcerations,  both 
topical  applications  and  submucous  in- 
jections are  advisable,  as  they  hasten  the 
separation  of  sloughing  tissue,  stimulate 
healthy  granulation,  and  at  the  same 
time  arrest  progress.  The  injection 
should  be  as  superficial  as  possible,  as  the 
primary  tubercular  deposit  is  immedi- 
ately beneath  the  epithelial  layer.  Weak 
solutions  of  cocaine  may  be  sufficient  in 
some  cases,  but  complete  antesthesia  is 
usually  necessary,  and  20-per-ceut.  solu- 
tions are  generally  the  most  satisfactory, 
administered  on  an  applicator, — although 
it  may  be  safe  to  employ  the  spray  if  the 
physician  is  well  acquainted  with  his 
patient.  Little  pain  or  reaction  follows 
the  injection  of  oily  solutions,  but  pure 
creasote  causes  a  burning  sensation  and 
considerable  soreness,  which  lasts  a  vari- 
able time.  Much  depends  on  the  locality 
of  the  injection ;  the  posterior  surface  of 
the  arytenoids  seems  to  be  specially  sensi- 
tive. There  is  little  or  no  hfemonhage 
after  the  needle  in  removed,  and  on  the 
following  day  the  mucous  membrane  is 
more  tense  and  possibly  somewhat  red- 
der. This  condition  subsides  in  the 
course  of  a  few  days,  leaving  the  tissues 
in  a  wrinkled  condition,  as  if  the  mucous 
membrane  were  too  large  for  the  sub- 
jacent parts.  Tliis  is  most  noticeable 
around  tlie  arytenoids.  Careful  judg- 
ment JH  required  to  determine  how  often 
tlic  injections  should  be  given,  but,  as  a 
rule,  it  should  be  once  in  five  or  six 
days.  If  ulceration  is  proceeding  rapidly, 
one  injection  may  be  given  daily   until 


three  or  four  have  been  administered. 
After  several  injections  it  is  well  to  wait 
for  a  time  and  see  if  the  circle  of  resolu- 
tion will  not  spread  from  the  point  of  in- 
jection to  the  neighboring  tissues. 

The  ventricular  bands  usually  require 
superficial  and  deep  injections,  the  former 
to  reach  the  deposits  in  the  bands,  and 
the  latter  the  ventricles  of  the  larynx. 
The  interarytenoid  space  should  be 
treated  from  below  upward,  otherwise  it 
would  be  impossible  to  obtain  a  good 
view  after  the  first  injection.  Very 
superficial  puncture  should  be  made  in 
the  mucous  membrane  covering  the 
arytenoids,  as  it  is  an  eas}'  matter  to 
start  a  perichondritis  in  this  situation. 
A  row  of  injections  should  first  be  made 
around  the  base  of  the  arytenoid  carti- 
lages and  gradually  approach  their  tips. 
Tubercular  infiltration  of  the  epiglottis 
renders  it  so  thick  and  firm  that  it  is 
capable  of  bearing  considerable  pressure 
and  is  readily  subjected  to  this  treat- 
ment. A  single  row  of  injections  may 
be  made  around  the  free  border  of  the 
epiglottis  about  half  an  inch  apart.  The 
lingual  surface  of  the  epiglottis  is  very 
accessible  for  injection,  but  the  laryngeal 
surface  is  not  so  easily  reached.  If  the 
ansesthesia  is  complete  the  epiglottis 
may,  in  some  cases,  be  pulled  forward 
sufficiently  by  the  shank  of  the  needle  for 
the  injections  to  be  made.  If  this  cannot 
be  effected,  the  needle  may  be  pushed 
through  the  cartilage  from  its  lingual 
surface.  After  the  injections  the  larynx 
should  be  kept  as  clean  as  possible,  and 
sprayed  every  day  or  so  with  the  weaker 
solution  of  creasote.  Chappell  (N.  Y. 
]\Ied.   Jour.,   Mar.   30,   '95). 

Creasote  in  lung  aiVection  is  somewhat 
discounted  by  the  irritant  effects  of  large 
doses,  leading  to  chronic  infianinuition 
of  the  alimentary  tract.  Creasotal  {crea- 
sote carbonate)  was  introduced  to  over- 
come tliis  advantage,  and  it  breaks  up 
in  the  intestine  into  creasote  and  carbonic 
acid.  The  decomposition  is  a  slow  one; 
so  that  the  organism  is  more  or  less  con- 
tinuously under  the  infiuence  of  creasote, 
which  is  excreted  by  the  lungs  and  kid- 
neys. It  may  be  given  alone  in  teaspoon- 
fuls.  or,  if  the  patient  is  very  susceptible 
to  its  slight  taste,  this  may  be  covered 


CEEASOTE.    THERAPEUTICS. 


351 


by  milk,  sweet  wine,  etc.  Very  large 
doses  (even  300  grains  per  day)  can  be 
administered  without  upsetting  the  di- 
gestion. Just  at  first  there  may  be  some 
nausea  or  even  vomiting,  but  these  do 
not  contra-indicate  the  continued  use  of 
the  drug,  as  they  soon  pass  oil'.  Creasote 
carbonate  has  precisely  the  same  specific 
action  upon  pulmonary  tuberculosis  as 
creasote;  in  addition  it  is  of  exceptional 
value  in  the  symptomatic  treatment,  di- 
minishing and  deodorizing  the  expectora- 
tion and  improving  the  appetite,  which 
may  even  become  ravenous  by  its  use. 
It  has  a  favorable  influence  on  the  gen- 
eral condition,  improving  nutrition  and 
leading  to  increase  of  body-weight,  and 
so  indirectly  limiting  the  spread  of  the 
lung  affection.  It  is  to  be  prefeiTcd  to 
creasote  because  of  its  milder  action,  and 
is  indicated  in  cases  where  the  latter  is 
tolerated  with  difficulty  or  not  at  all. 
Reiner  (Inter,  klin.  Rund.,  Sept.  15,  '95; 
Brit.  Med.  Jour.,  Jan.  25,  '96). 

Creasote  valerianate  may  be  given  in 
capsules,  3  minims  thrice  daily,  and 
slowly  increased  until  from  25  to  30 
minims  can  be  taken  during  the  twenty- 
four  hours.  Its  use  with  thirty-five  pa- 
tients evidences  it  as  an  excellent  sub- 
stitute for  pure  creasote.  Grawitz  (Ther. 
Monats.,  vol.  vii,  '9G). 

Creasote  possesses  undoubted  power  to 
relieve  the  foetor  of  foul  expectoration  in 
bronchiectasis  and  phthisis.  It  modifies 
in  a  very  appreciable  manner  the  oi'- 
dinary  course  of  the  latter  disease. 
Shrady  (Med.  Rec,  June,  '90). 

Creasote  is  one  of  the  most  efficient 
remedies  in  pulmonary  tuberculosis. 
Probably  no  one  drug  e.xerts  so  favorable 
an  action  on  the  night-sweats,  cough,  and 
expectoration.  It  is  of  less  value  in 
cases  accompanied  by  high  temperature 
and  htcmoptysis,  and  often  aggravates 
these  symptoms.  It  must  be  remem- 
bered that  many  of  the  cases  alleged  to 
have  been  cured  by  creasote  have  been 
treated  with  codliver-oil,  tonics,  and 
hygienic  method,  as  well.  In  any  event, 
large  doses  are  necessary,  and  tolerance 
can  usually  be  established  by  gradually 
increasing.  Capsules  are  the  least  offen- 
sive mode  of  administration,  though  some 
persons  prefer  to  take  the  drug  in  milk. 


Butler      (''Text-book     of     Mat.     Med., 
Therap.,  and  Pliarm.,"  '96). 

Creasote  in  full  doses  is  strongly  rec- 
ommended in  phthisis,  especially  in  non- 
febrile  or  only  slightly-feverish  cases.  It 
is  said  to  diminish  expectoration,  im- 
prove appetite,  and  increase  weight.  A 
good  formula  is 

R  Creasote,  2  minims. 

Com.  tincture  gentian,  15  minims. 

Rectified  spirit,  20  minims. 

Water,  to  make  1  ounce. 
'M.    For  one  or  two  doses. 

The  creasote  in  this  mixture  may  be 
increased  up  to  10  or  even  12  minims 
without  increasing  the  other  ingredients. 
Ringer  and  Sainsbury  ("Hand-book  of 
Therap.,"  '97). 

One  hundred  and  three  cases  of  pul- 
monary tuberculosis  studied.  The  dosage 
of  creasote  began  with  5  minims  three 
times  daily,  gradually  increased  to  25; 
also  generous  diet  insisted  upon,  along 
with  weighing  at  regular  intervals.  In 
not  a  single  instance  was  appetite  un- 
favorably influenced.  Cough  and  ex- 
pectoration steadily  improved,  and  in 
most  the  physical  signs  were  either  the 
same  or  indicated  less  involvement  of  the 
lung.  It  is  apparent  that  the  remedy 
favorably  influences  the  fever  and  night- 
sweats,  and  that  it  is  superior  to  others 
in  that  it  does  not  interfere  with,  but 
rather  favors,  the  nutrition  of  the  pa- 
tient. Jacob  and  Nordt  (Berliner 
Charite-Annalen,  S.  159,  '97). 

In  the  treatment  of  phthisis  the  drug 
is  well  borne.  Of  23  cases,  6  were  in 
the  pretubercular  state, — catarrh  of  the 
apices, — and  I"  had  already  developed 
tuberculosis,  and  all  were  markedly 
benefited.  Woodbury  (X.  Y.  Med.  Jour., 
Sept.  4,  '97). 

■Whooping-cough. — Both  creasote  and 

carbolic  acid,  by  inhalation,  often  prove 

of  great  value  in  this  malady,  but  it 

should  not  be  persisted  in  if  they  induce 

giddiness  or  a  sensation  of  intoxication. 

Creasote  seems  especially  useful  when 

the  cough  is  \nolent  and  protracted,  and 

out  of  all  proportion  to  the  amount  of 

expectoration,  when,  indeed,  the  cough 

seems  largely  to  depend  on  an  excitable 


352 


CREASOTE. 


state  of  the  nerves.  Its  effect  is  often 
rapid  and  complete;  in  fact,  there  are 
few  remedies  that  afford,  in  some  eases, 
so  much  and  so  rapid  relief.  Kinger  and 
Sainsbury  ("Hand-book  of  Therap.,"  '97). 
Brilliant  results  are  had  from  the  use 
of  creasote,  not  only  in  phthisis,  but  in 
the  sequels  of  whooping-cough,  and  the 
catarrh  which  often  follows  measles:  two 
conditions  which  aft'ord  favorable  oppor- 
tunity for  tuberculous  infection.  The 
usual  treatment  by  means  of  expecto- 
rants is  too  often  without  results.  Hock 
(Tex.  Med.  Prac,  Nov.,  "97). 

Bronchitis  and  Bhonchiectasis. — 
Bronchitis  is  another  malady  in  which 
the  drug  sometimes  appears  very  useful. 
In  bronchiectasis  it  has  been  strongly 
recommended  by  Chaplin.  (See  Bron- 
chiectasis.) 

The  inhalation  of  steam  impregnated 
with  creasote,  10  to  20  minims  to  a  pint 
of  hot  water   (140°   F.),  is  valuable  in 
some  cases,  lessening  overabundant  ex- 
pectoration.    It  will  generally,  also,  re- 
move the  foetor  of  the  breath  occasionally 
met  with,  and  sometimes  even  that  due 
to  gangrenous  lung.     Ringer  and  Sains- 
bury ("Hand-book  of  Therap.,"  '97). 
Pneumonia. — Because  of  its  expecto- 
rant and  stimulating  qualities,  recently 
the  drug  has  been  advantageously  used 
as  a  remedy  in  this  disorder. 

In  20  eases  of  pneumonia,  forming  part 
of  a  somewhat  serious  epidemic,  it  was 
given  on  tlie  third  day.  All  recovered. 
Some  treated  with  creasote  in  tincture 
of  gentian  alone;  in  others  this  was 
supplemented  by  digitalis  or  caffeine  in 
small  doses.  The  cases  treated  with 
creasote  recovered  more  rapidly  and  more 
thoroughly  than  tho.se  treated  in  other 
ways.  No  unpleasant  effects  supervened 
from  its  use.  Casati  (Biit.  Med.  .Jour., 
vol.  i,  '97). 

CRETINISM.     See  Infantile  Myx- 

CEDEMA. 

CROUP. 

Definition  and  Varieties. — Confusion 
Btill  e.viKts  in  the  classification  and  no- 


menclature of  diseases  of  the  larynx  in 
children.  This  is  due  largely  to  the  fact 
that  those  diseases  are  not  well  defined, 
but  merge  into  each  other.  In  young 
children  two  elements  are  to  be  detected 
in  laryngeal  affections:  catarrh  and 
spasm.  Two  forms  of  croup  have,  there- 
fore, been  described:  the  catarrhal  and 
the  spasmodic.  Such  a  classification 
seems,  however,  unnecessary  and  confus- 
ing. Catarrh  and  spasm  are  present  in 
all  eases,  one  being  predominant  in  one 
instance,  the  other  in  another.  A  slight 
degree  of  catarrhal  inflammation  is  in- 
variably present.  The  form  of  spas- 
modic croup  marked  only  by  spasm  with 
no  evidence  whatever  of  catarrh,  as  de- 
scribed by  some  authors,  is  extremely 
rare,  if  it  ever  occurs.  There  is  invari- 
ably present  a  more  or  less  decided  ca- 
tarrhal element;  tracheitis  and  bronchitis 
are  prone  to  follow.  In  most  cases,  at 
the  outset,  the  laryngeal  spasm  overshad- 
ows the  catarrhal  element;  later,  the  ca- 
tarrhal becomes  more  prominent.  The 
disease  may  be  mild  or  very  severe.  Many 
authors,  therefore,  describe  two  forms — 
a  mild  and  a  severe  type;  but  these  forms 
differ  in  degree  rather  than  in  kind. 

Catarrhal  Croup. 

Symptoms. — In  rare  instances  the  on- 
set of  catarrhal  croup  is  sudden,  with  no 
premonitory  symptoms.  More  commonly 
the  child  has  a  slight  cough  and  coryna 
and  becomes  hoarse  during  the  afternoon 
and  perhaps  feverish  in  the  evening. 
Late  in  the  evening  the  cough  becomes 
loud,  dry,  and  hoarse,  its  characteristics 
being  peculiar  and  distinctive.  In  the 
great  majority  of  cases  this  occurs  be- 
tween the  hours  of  nine  and  twelve.  The 
child  wakes  suddenly  with  the  character- 
istic cough  and  begins  to  struggle  for 
breath.  lie  frequently  becomes  alarmed 
at  his  inability  to  breathe,  and  his  fright 
adds  to  the  severity  of  the  symptoms. 


CROUP.     CATARRHAL.     DIFFERENTIAL  DIAGNOSIS. 


353 


In  attacks  of  ordinary  severity  the 
respiration  is  loud  and  noisy;  the  voice 
is  hoarse,  but  rarely  lost;  the  dyspnoea 
is  sometimes  extreme  and  the  respiration 
so  noisy  that  it  can  be  heard  in  an  ad- 
joining room.  The  loud  metallic  cough 
is  very  different  from  the  stridulous,  sup- 
pressed cough  of  a  well-developed  case 
of  pseudomembranous  laryngitis.  There 
is  frequently  extreme  recession  of  the 
various  thoracic  spaces.  The  tempera- 
ture is  usually  somewhat  elevated,  but 
rarely  reaches  103°.  The  lips  and  nails 
frequently  assume  a  purplish  hue,  but 
are  rarely  cyanotic.  There  is  often  a  dis- 
charge from  the  nose,  and  the  eyes  are 
sometimes  congested  and  watery;  con- 
ditions not  usually  present  in  pseudo- 
membranous croup.  After  two  or  three 
hours  the  symptoms  usually  subside.  Oc- 
casionally they  appear  in  less  severe  form 
later  in  the  night,  but,  as  a  rule,  all 
urgency  is  passed  by  early  morning.  In 
some  instances  the  child  is  almost  as  well 
as  usual  during  the  following  forenoon 
and  shows  but  little  evidence  of  the  ex- 
periences of  the  night.  The  attack,  how- 
ever, is  usually  repeated  during  the  fol- 
lowing night,  and  may  recur  for  several 
nights,  becoming  less  severe  with  each 
succeeding  attack.  In  my  experience, 
however,  this  freedom  from  symptoms  on 
the  following  day  is  extremely  rare. 
Jlore  commonly  the  child  continues  to 
be  feverish  and  has  a  troublesome  cough, 
although  it  may  not  be  croupy  in  char- 
acter. In  the  damp  climate  of  New  York 
and  vicinity  an  attack  of  croup,  as  a  rule, 
is  but  the  initial  symptom  of  a  bronchial 
or  laryngeal  catarrh,  whicli  requires  sev- 
eral days  or  a  week  or  more  to  run  its 
course.  Attacks  more  mild  in  form,  but 
similar  in  nature,  are  of  frequent  occur- 
rence and  must  be  considered  as  simply 
mild  attacks  of  croup.  In  other  in- 
stances the  attack  appears  to  be  really 


one  of  bronchitis,  with  a  dry  and  croupy 
cough  at  night. 

Differential  Diagnosis.  —  In  typical 
cases  of  catarrhal  croup  the  diagnosis  is 
evident  at  a  glance.  The  sudden  onset 
during  the  early  hours  of  the  night; 
the  immediate  development  of  extreme 
symptoms;  the  loud  metallic  cough;  the 
noisy  respiration;  and  the  terror  of  the 
child,  all  combine  to  form  a  very  char- 
acteristic clinical  picture.  In  less  typ- 
ical cases,  however,  the  diagnosis  is  some- 
times dilficult. 

Catarrhal  croup  should  be  distin- 
guished from  acute  catarrhal  laryngitis. 
The  latter  disease  may  be  primary,  sec- 
ondary to  the  infectious  diseases,  or 
traumatic.  The  lesions  are  found  chiefly 
in  the  mucosa  and  lymphoid  tissue  of 
the  subglottic  region,  and  in  severe  cases 
they  may  be  so  pronounced  as  to  cause 
laryngeal  stenosis.  This  disease  is  fre- 
quently a  complication  of  bronchitis. 
It  is  marked  by  hoarseness  and  a  fre- 
quent, harassing,  metallic  cough,  which 
always  becomes  worse  at  night  and  is 
usually  aggravated  by  lying  do\vn.  The 
milder  and  more  common  cases  are  usu- 
ally seen  in  children  between  one  and 
six  years.  Although  extremely  annoy- 
ing, they  are  rarely  dangerous  or  fatal. 
A  severe  type  is  sometimes  seen,  how- 
ever, which  may  prove  fatal.  In  this 
type  the  temperature  is  high;  the  voice 
is  metallic  and  may  be  suppressed;  Iar}Ti- 
geal  stenosis  may  become  so  great  as  to 
demand  intubation.  This  disease  is  dif- 
ferentiated from  pseudomembranous  lar- 
yngitis with  the  greatest  difficulty. 

The  disease  may  be  mistaken  for  pseu- 
domembranous croup,  laryngismus  strid- 
ulus, and  even  pneumonia.  The  presence 
of  foreign  bodies  in  the  larynx  must  be 
excluded,  as  well  as  retropharyngeal  ab- 
scess. The  sudden  onset,  remission  of 
symptoms,  hoarseness  without  loss  of 
23 


354 


CKOUP.    CATAKRHAL.    ETIOLOGY.    PATHOLOGY. 


Toice,  loud  metallic  cough,  with  little  or 
no  stridor,  and  the  response  to  treat- 
ment usually  suffice  to  distinguish  ca- 
tarrhal croup  from  pseudomembranous 
croup,  with  its  insidious  onset;  slower, 
but  more  steady  and  unremitting,  course; 
suppressed  voice  and  cough,  increasing 
cyanosis,  embarrassed  expiration,  and 
characteristic  stridor.  Larj'ngitis  strid- 
ulus is  a  disease  of  early  infancy.  The 
symptoms  occur  in  paroxysms,  which  are 
usually  repeated  many  times  a  day  and 
occur  at  no  definite  hour.  They  are  un- 
accompanied bj'  any  evidences  of  ca- 
tarrh. The  disease  invariably  occurs  in 
rachitic  infants,  and  is  a  frequent  accom- 
paniment of  tetany  or  general  convul- 
sions. 

The  onset  of  non-baoillary  croup  is 
much  more  sudden  than  that  of  diph- 
theria, and  the  temperature  rises  more 
quickly  and  to  a  higher  point.  The  mem- 
brane has  not  the  dead-white  appearance 
of  diphtheritic  membrane.  It  is  yellow- 
ish in  color,  softer,  less  firmly  matted 
together,  and  more  easily  detached  from 
the  underlying  tissues.  Placed  in  water, 
the  membrane  swells  up,  losing  its  char- 
acteristic shape.  The  surface  from  which 
the  membrane  has  been  detached  is  sel- 
dom bleeding  or  ulcerated,  and  may 
preserve  its  epithelium  quite  intact.  Ex- 
amined microscopically,  the  membrane  is 
found  to  consist  of  pus-cells,  leucocytes, 
and  fibrin.  J.  0.  Synies  (Bristol  Medico- 
Chir.  Jour.,  Mar.,  1900). 

I  have  twice  been  called  in  consulta- 
tion to  find  broncho-pneumonia  in  young 
children  in  which,  when  dry,  difficult 
cough  combined  with  an  unusual  degree 
of  expiratory  dyspnoea  had  been  mis- 
taken for  croup. 

Etiology. — Age  is  an  important  pre- 
disposing cause  of  the  disease,  which  is 
most  common  between  two  and  five 
years.  It  is  very  rare  under  one  year 
and  over  eight.  It  may  occur,  however, 
at  any  time  until  adolescence,  and  I  have 
seen  a  typical  case  in  an  adult. 


Case  of  croup,  with  fatal  termination, 
observed  in  a  lady  of  00  years,  who  had 
had  several  attacks  of  spasmodic  croup 
at  about  40  years  of  age.    Waxham  (No. 
Amer.  Pract.,  Sept.,  "91). 
Heredity  is  also  an  important  predis- 
posing cause,  the  disease  occurring  with 
especial  frequency  in  some  families.    En- 
larged tonsils  and  adenoid  growths  also 
predispose  to  croup.     It  is  sometimes 
brought  on,  apparentlj',  by  atmospheric 
conditions,  as  it  is  not  uncommon  to 
see  several  cases  at  about  the  same  time. 
It  cannot,  however,  be  called  an  epi- 
demic disease.    Exposure  to  cold  is  un- 
doubtedly the  most  important  and  excit- 
ing cause.    Excessive  use  of  the  voice  in 
damp  and  cold  weather  is,  also,  a  fre- 
quent cause.    Indigestion  will  often,  un- 
doubtedly  precipitate   an    attack   in    a 
sensitive  child. 

The  rapidity  of  onset  and  severity  of 
symptoms  may  at  times  suggest  diph- 
theria. A  reliable  bacteriological  ex- 
amination of  the  throat  is  prerequisite. 
Antitoxin,  although  to  be  used  in 
doubtful  cases,  will  be  of  no  service  in 
cases  in  which  the  Klebs-LoetHer  organ- 
ism is  not  the  causative  factor.  The 
above  may  be  taken  as  examples  of 
eases  at  times  diagnosed  as  diphthei'ia. 
in  which  no  microscopical  examination 
is  made.  Moreover,  the  failures  of  anti- 
toxin are  often  credited  to  such  cases. 
The  author  emphasizes  the  importance 
of  a  careful  analysis  of  each,  basing  the 
diagnosis  on  both  clinical  and  bacteri- 
ological evidence.  F.  P.  Anzinger 
(Amer.  Jour.  Med.  Sciences,  Nov.,  1904). 

Pathology. — The  lesions  of  catarrhal 
croup  are  found  chiefly  above  the  vocal 
cords  and  are  those  common  to  all  ca- 
tarrhal inflammations  of  the  mucous  sur- 
faces. The  spasmodic  symptoms  are  due 
chiefly  to  spasm  of  the  adductors.  The 
disease  may  appear  primarily  in  the 
larynx  or  it  may  extend  from  the  naso- 
pharynx downward  or  more  rarely  from 
the  trachea  upward. 


CROUP.     CATARRHAL.     PROGNOSIS.     TREATilEXT. 


355 


Prognosis.  —  Ordinary  types  of  ca- 
tarrhal croup  are  never  fatal.  In  very 
rare  instances  in  which  the  catarrhal  ele- 
ment predominates  and  is  very  severe, 
the  prognosis  may  be  grave.  In  other 
words,  catarrhal  croup  is  rarely  or  never 
fatal,  while  severe  catarrhal  laryngitis 
with  spasm  may  be  a  dangerous  disease. 

Treatment.  —  Preventive  treatment 
consists  in  the  removal  of  all  evident 
exciting  causes,  such  as  enlarged  tonsils 
and  adenoid  growths,  and  in  the  relief 
of  indigestion.  Exercise  in  the  open  air 
is  important,  but  the  child  must  be  prop- 
erly clad,  and  all  exposure  should  be 
avoided.  Screaming  and  excessive  use  of 
the  voice  while  at  play  during  damp  and 
stormy  weather  should  be  prohibited. 
Anaimic  and  delicate  children  should  re- 
ceive proper  constitutional  treatment. 
Relief  of  the  paroxysms  may  be  sought 
by  external  application  and  medical 
treatment.  A  large,  hot  poultice  over 
the  throat  and  chest  will  do  much  to 
relax  the  spasm.  A  large  bath-sponge 
saturated  with  water  as  hot  as  the  child 
can  bear  and  applied  to  the  throat  is 
almost  as  effective  as  a  poultice  and  is 
more  readily  managed.  Vigorous  rub- 
bing with  hot,  camphorated  oil  is  also 
efficacious.  The  use  of  the  croup-kettle 
and  tent  will  sometimes  prove  more  ef- 
fectual in  stubborn  cases  than  any  other 
measure.  The  steam  seems  to  be  the 
effective  agent,  but  is  somewhat  aided  by 
the  addition  of  volatile  substances,  par- 
ticularly creasote  in  small  amount. 

Among  drugs,  ipecac,  opium,  and  anti- 
pyrine  have  proved  most  efficacious  in 
my  experience.  If  there  is  acute  indi- 
gestion, emesis  through  the  use  of  ipecac 
will  sometimes  check  the  attack  perma- 
nently. In  other  cases  emesis  is  not  usu- 
ally followed  by  complete  and  permanent 
relief.  The  wine  of  ipecac  is  more 
prompt  and  clTcctivo  in  its  action  than 


the  syrup.  Opium  I  have  found  the 
most  efficacious  drug  in  checking  spasm. 
One  full  dose,  adapted  to  the  age  of  the 
child,  may  be  given,  but  the  ipecac  may 
be  repeated  several  times.  It  is  not  best 
to  produce  vomiting.  During  recent 
years  I  have  used  chiefly  tablet  tritu- 
rates of  brown  mixture,  the  active  princi- 
ples of  which  are  opium  and  antimony. 
Antipyrine  is  an  extremely  effective  drug 
in  most  cases,  but  sometimes  fails  to 
give  material  relief.  The  best  results 
are  seen  from  its  use  when  the  catarrhal 
element  is  slight  and  the  spasmodic  ele- 
ment marked.  It  is  a  comparatively- 
safe  drug  for  use  among  children.  Two 
grains  may  be  given  at  two  years,  half 
the  dose  to  be  repeated  in  one  hour  if 
necessary.  My  most  common  plan  of 
treating  the  paroxysm  is  as  follows: 
After  evacuation  of  the  stomach  and 
bowels  in  case  of  indigestion  or  constipa- 
tion, a  hot  sponge  or  poultice  is  applied 
to  the  throat  and  a  full  dose  of  antipyrine 
and  brown  mixture  (mistura  glyc3T- 
rhizcB  comp.)  is  administered,  the  latter 
in  the  form  of  tablet  triturate.  If  no 
relief  is  manifest  in  forty-five  minutes, 
a  second  dose  is  given,  while  a  few  10- 
drop  doses  of  wine  of  ipecac  are  given 
in  the  interval. 

Relief  of  the  muscular  spasm  can  be 
accomplished  very  effectually  by  spray- 
ing the  mucous  membrane  of  the  throat 
with  a  2-per-cent.  solution  of  cocaine. 
A.  O.  Stiinpson  (Med.  and  Surg.  Re- 
porter, Jlar.  27,  '97). 

Coal-oil,  in  doses  of  15  to  30  drops  on 
sugar,  or  syrup,  every  fifteen  or  thirty 
minutes,  according  to  age  and  severity 
of  the  case,  is  of  great  value.  It  may 
also  be  used  with  turpentine  and  lard, 
on  throat  and  chest.  Caspar  Q.  West 
(Med.  Brief,  June,  '97). 

On  the  following  day  cough  or  bron- 
chitis is  treated  by  the  use  of  bro\N-n  mixt- 
ure  given    in    doses    indicated    by    the 


356 


CKOUP.     MEMBKAKOUS.     SYMPTOMS. 


symptoms  and  the  age  of  the  child. 
They  maj'  be  increased  in  frequency  as 
night  approaches.  Antipyrine  is  very 
effective  in  preventing  recurrence  on  the 
following  nights.  Two  grains  adminis- 
tered in  the  afternoon  and  again  in  the 
evening  will  alone  frequently  prevent  the 
attack.  It  can,  however,  he  given  in 
addition  to  the  usual  cough-mixture. 

Creosotal  used  in  croup,  with  pro- 
nounced success.  In  one  case  a  com- 
plicating pneumonia  was  checked  at  its 
onset  and  a  favorable  change  in  the 
croup  itself  brought  about  over  night. 
Two  similar  cases  also  improved  rap- 
idly, while  some  of  those  treated  with 
serum  died.  In  pseudocroup  a  dose  suf- 
ficiently large  to  cause  the  character- 
istic odor  about  the  breath  and  per- 
spiration must  be  given;  when  the  fever 
falls,  smaller  doses  are  employed  for 
some  time  to  prevent  a  recurrence.  L. 
Lasansky  (Deutsche  med.  Weitsch.,  Nov. 
13,  1902). 

Membranous  Croup. 
The  etiology  and  nature  of  pseudo- 
membranous laryngitis  was  for  years  the 
subject  of  much  discussion.  The  ques- 
tion has  at  last  been  settled  by  the  bac- 
teriologist, who  has  demonstrated  that 
in  the  great  majority  of  cases  the  disease 
is  diphtheritic.  It  is  equally  demon- 
strated, also,  that  a  certain  proportion 
of  cases  are  not  diphtheritic. 

Membranous  croup  and  diphtheria  are 
differentiated  by  the  following  points: 
The  membrane  of  diphtheria  is  of  a 
yellowish  hue,  the  temperature  of  the 
body  rather  high,  and  the  membrane  ia 
a^>t — in  fact,  certain — to  curl  up  at  the 
edges;  while  in  membranous  croup  the 
membrane  is  white,  does  not  curl  at 
the  edges,  is  devoid  of  all  peculiar  odor, 
and  the  temperature  is  rather  low.  Carl 
Seller  (Jour,  of  Laryngology,  Aug.,  '90). 

Of  28G  cases,  reported  by  Park  and 
Beebe,  the  Klebs-LoefTler  bacillus  was 
present  in  229.  In  the  remaining  57 
cases  it  was  not  present,  Init  in  17  the 


examination  was  not  satisfactory.  The 
observations  of  recent  years  have  shown 
that  a  pseudomembrane  developing  pri- 
marily in  the  larjoix  is  almost  invariably 
associated  with  the  Klebs-Loeffler  ba- 
cillus; that  is,  it  is  true  diphtheria. 
Pseudomembranous  inflammation  of  the 
larynx  secondary  to  diphtheritic  inflam- 
mation of  the  pharynx  is  invariably  true 
diphtheria.  A  pseudomembrane  devel- 
oping in  the  larjTix  secondarily  to  the 
pseudomembranes  which  develop  during 
the  course  of  the  infectious  diseases  is 
commonly  pseudodiphtheria.  Such  pseu- 
domembranes are  associated  with  micro- 
organisms other  than  the  Klebs-Loefller 
bacillus,  generally  the  streptococcus. 

Case  of  pneumococcio  croup  in  a  child 
of  S  years,  who,  during  an  attack  of 
influenza,  manifested  an  erythematous 
angina.  Laryngeal  stenosis  rapidly  su- 
pervened and,  despite  the  injection  of 
Koux's  antitoxin,  called  for  tracheotomy 
on  the  evening  of  the  same  day.  The 
wound  gave  issue  to  a  false  membrane  of 
colloid  appearance,  which  gave  a  pure 
culture  of  the  pneumococcus.  The  case 
recovered.  Seuvre  (Revue  Men.  desMal. 
de  TEnfanee,  Mar.,  '98). 

A^Hiatever  the  cause  of  the  disease, 
whether  bacillus  or  streptococcus,  it 
manifests  itself  simply  as  a  pseudomem- 
branous laryngitis,  stenosis  being  the  im- 
portant symptom. 

Symptoms. — As  the  disease  is  so  fre- 
quently diphtheritic  in  nature,  it  will  be 
considered  in  detail  in  the  section  on 
diphtheria.  Owing  to  the  slow  absorp- 
tion of  toxins  by  the  laryngeal  mucous 
membrane  and  the  comparatively  short 
course  of  the  disease  when  confined  to 
the  larynx,  the  constitutional  symptoms 
of  diphtheria  are  slight.  Hence,  croup 
pursues  practically  the  same  course 
whether  due  to  diphtheria  or  pseudo- 
diphtheria.  It  is  impossible  from  clin- 
ical evidence  alone  to  determine  whether 


CROUP.     MEMBRANOUS.     PATHOLOGY.    PROGNOSIS.     TREATMENT. 


357 


the  disease  is  true  or  false  diphtheria.  As 
it  is  true  diphtheria  in  a  very  large  pro- 
portion of  cases,  the  only  safe  rule  in 
practice  is  to  consider  every  case  of  croup 
to  be  diphtheritic  and  to  use  precautions 
accordingly. 

Pathology.- — In  some  cases  the  an- 
terior portion  of  the  larynx  alone  is  in- 
volved by  pseudomembrane.  In  other 
cases  the  whole  mucous  membrane  of  the 
larynx  is  covered.  In  many  instances  the 
membrane  does  not  pass  below  the 
larynx.  In  both  true  and  pseudodiph- 
theria  the  membrane  is  but  one  element 
in  the  production  of  stenosis,  oedema  and 
swelling  of  the  tissue  underneath  the 
pseudomembrane  being  an  important 
contributing  cause. 

Prognosis. — Unlike  pseudodiphtheria 
of  the  pharynx,  pseudodiphtheria  of  the 
larynx  is  almost  equally  fatal  with  true 
diphtheria,  as  it  causes  death  by  me- 
chanically obstructing  respiration.  Un- 
til a  few  years  ago  the  age  of  the  infant 
was  the  most  important  factor  in  prog- 
nosis, the  younger  the  child,  the  more 
fatal  being  the  disease. 

Tlie  younger  the  patient,  the  higher 
the  mortality,  because  of  the  small  size 
of  the  trachea  and  larynx  and  because 
stenosis  sooner  results;  the  prognosis  is 
unfavorable  in  the  mildest  cases;  un- 
favorable symptoms  are  increasing  de- 
bility and  cyanosis,  feeble  and  irregular 
pulse,  and  the  development  of  bronchitis 
or  broncho-pneumonia.  Dodge  (Med.  and 
Surg.  Rep.,  Mar.  21,  '91). 

Age  is  still  a  very  important  factor, 
but  prompt  treatment  with  antitoxin 
must  be  considered  of  far  greater  im- 
portance in  modifying  the  prognosis. 

Treatment.— The  efficacy  of  the  anti- 
toxin treatment  of  diphtheria  has  been 
too  fully  established  to  permit  of  doubt 
or  argument.  It  is  more  effective  in 
croup  than  in  any  other  form  of  diph- 
theria.   An  injection  should  be  given  on 


a  clinical  diagnosis  without  waiting  for 
a  bacteriological  examination.  Its  early 
use  will,  in  a  large  proportion  of  cases, 
prevent  the  necessity  of  operation.  Xext 
to  the  antitoxin  treatment,  calomel  fumi- 
gations have,  in  my  experience,  proved 
most  efficacious. 

[Vaporization  of  calomel:  A  powder 
consisting  of  from  15  to  30  grains  (1  to 
2  grammes)  of  calomel  is  placed  upon  a 
tin  plate,  and  heat  applied  until  all  of 
the  powder  has  been  vaporized;  this 
should  be  done  under  a  tent  erected  over 
the  patient's  bed,  the  curtains  of  which 
should  be  kept  closed  for  ten  minutes 
to  a  half-hour  after  each  fumigation. 
Dense,  white  fumes  are  evolved,  which 
are  not,  however,  irritating  to  the  pa- 
tient, and  the  change  in  the  respiratory 
sound,  after  the  first  burning  of  the 
calomel,  is  sometimes  very  marked. 
There  have  been  no  cases  of  salivation 
reported  as  yet  in  patients,  but  nurses 
and  people  who  have  to  be  in  the  room 
during  sublimation  of  the  calomel  have, 
in  several  instances,  been  salivated ;  so 
due  care  must  be  exercised.  J.  Lewis 
Smith  and  Frederic  M.  Warxer, 
Assoc.  Eds.,  Annual,  '93.] 

Calomel  fumigation  in  the  treatment 
of  croup  is  the  most  valuable  means  of 
medication  in  this  disease  possessed  at 
present  (1893),  and  will  save  a  larger 
percentage  of  cases  without  the  aid  of 
surgery  than  any  other  method  of  treat- 
ment. It  is  also  capable  of  doing  much 
harm.  From  10  to  20  grains  may  be 
used,  according  to  the  size  of  the  tent 
in  which  the  patient  is  placed,  every  two 
hours  during  the  first  day,  increasing  the 
interval  to  three  hours  on  the  second 
day,  and  so  on,  according  to  the  prog- 
ress of  the  disease.  The  patient  should 
be  left  in  the  tent  for  fifteen  minutes 
at  each  sitting  and  the  flame  of  the 
spirit-lamp  so  regulated  that  the  calo- 
mel all  evaporates  within  this  time. 
Nurses  or  attendants  who  remain  much 
in  the  same  room  soon  become  ptyalized 
and  older  children  occasionally  show 
constitutional  pfTects.  In  order  to  obtain 
the  best  results,  the  fumigation  should 
be  resorted  to  early,  or  before  the  mu- 


358 


CKOUP.    MEMBKAXOUS.    TER.A.TMEXT. 


cous  membrane  becomes  lined  with  a 
layer  of  pseudomembrane.  George  Mc- 
Xa lighten  and  William  Maddem  (Brook- 
lyn Med.  Jour.,  Aug.,  '93). 

Case  of  a  child  with  true  croup  in 
which  intense  dyspnoea  was  present;  be- 
fore resorting  to  tracheotomy,  inhala- 
tions of  vaporized  calomel,  30  grains, 
were  resorted  to,  with  entire  success;  in 
ten  minutes  the  patient  was  quiet  and 
comfortable  and  without  dyspnoea.  The 
next  day  the  same  symptoms  reappeared, 
and  like  treatment  was  resorted  to  with 
equal  success;  on  the  fourth  day  the 
child  was  convalescent.  Eothn  (Der 
Kinder- Arzt.,  Mar.,  '90). 

Intubation      should      be      performed 
promptly  when  indicated. 

The  following  are  indications  for  the 
performance  of  intubation:  Given  a  case 
of  membranous  laryngitis,  with  hoarse- 
ness increasing  to  whispering,  with  cough 
short  and  explosive,  becoming  high- 
pitched  and  prolonged,  diminution  of  or 
absence  of  the  vesicular  breathing,  over 
the  lower  posterior  lobes  of  the  lungs, 
beginning  recession  of  the  epigastrium 
and  beginning  restlessness,  the  call  is  for 
immediate  removal  of  the  obstruction. 
Xote  especially  the  character  of  the 
voice  and  cough;  if  these  become  pro- 
gressively worse,  the  child's  best  interests 
will  be  served  by  delaying  no  longer  the 
necessary  intubation.  Ground  (North- 
western Lancet,  Sept.  1,  '91). 

[There  are  only  two  impedimenta  to 
the  introduction  of  a  tube  of  proper  size 
in  any  form  of  acute  stenosis  of  the 
larynx,  viz.:  entering  one  of  the  ven- 
tricles or  a  subglottic  stenosis.  Neither 
spasm  of  the  glottis,  nor  pseudomem- 
brane, nor  oedema,  when  situated  in  or 
above  the  chink,  ever  ofTcrs  any  serious 
objection  to  the  passage  of  a  tube.  J. 
O'DwvER,  Assoc.  Ed.,  Annual,  '92.] 

Result  of  a  collective  investigation  on 
intubation  in  Germany  including  1445 
cases  intubated  for  the  relief  of  croup: 
there  were  5.'>3  recoveries,  or  38  per  cent. 
One  hundred  and  twenty-one  of  the 
cases  were  secondary  to  measles,  scarlet 
fever,  pneumonia,  etc.  Secondary  trache- 
otomy was  resorted  to  in  250  of  the 
casts,  with  only  20  recoveries,  or  about 


7  per  cent.  This  number  proves  for  it- 
self that  the  dangers  which  were  for- 
merly charged  against  this  operation 
must  have  been  greatly  exaggerated. 
Kanke  (Jliinchener  med.  Woeh.,  No.  44, 
■93). 

Individual     experience    in    500    cases 
treated   by   intubation:    there   was   not 
a  single  death  from  pushing  down  mem- 
brane before  the  tube.     When  this  acci- 
dent, which  was  uncommon,  did  occur, 
the  obstructing  membrane  was  usually 
expelled  after  the  withdrawal  of  tlie  tube. 
The  string  is  always  left  attached,  and, 
if  passed  through  a  piece  of  fine  rubber 
tubing,    which    stands    a    good    deal'  of 
chewing,  it  will  avoid  being  cut  by  the 
teeth.      Bukai    (Jalubuch    fiir   Kinderh. 
und  physische  Erziehung,  June  5,  '94), 
The  results  obtained  by  the  use  of  anti- 
toxin, followed,  when  necessary,  by  in- 
tubation, have  robbed  one  of  the  most 
deadly  diseases  of  many  of  its  terrors. 
(See  DirnxHERiA.) 

Tracheotomy  for  croup  from  December, 
ISSO,  to  February,  1892,  115  times;  re- 
coveries, 39.93  per  cent.;  5  cases  died 
during  the  operation.  Bajardi  (Archivio 
Ital.  di  Ped.,  July,  '92). 

Five  hundred  and  seventy-two  trache- 
otomies performed  in  six  years  for  croup; 
of  these  cases,  310,  or  55  '/,  per  cent., 
died.      Hagcdorn    (Deut.    Zeit.    f.    Chir., 
B.  33,  H.  6,  '93). 
Among   the    other   measures    recom- 
mended, turpentine  and  hydrochlorate  of 
ammonia  hold  a  prominent  place,  but  the 
measures  already  outlined  are  to  be  pre- 
ferred. 

Turpentine  in  niembranous  croup  is  of 
extreme  value.  The  drug  should  be 
administered  in  dracliiu-doses,  repeated 
every  hour  for  from  four  to  six  doses, 
then  suspended  for  six  or  eight  hours. 
The  membrane  becomes  of  a  muddy- 
yellow  color,  and  is  thrown  ofT.  If  this 
change  does  not  take  place,  recourse 
should  be  had  again  to  the  turpentine 
for  three  or  four  doses.  S.  L.  McCurdy 
(Columbus  Med.  Jour.,  Apr.,  '90). 

Turpentine  internally  in  large  doses 
recommended.  In  13  cases  of  croup 
treated  willi  diUflnnilDscH  of  turpentine, 


CUBEB.    PREPARATIONS  AND  DOSES. 


359 


there  were  8  recoveries.  In  only  one 
case  was  any  disagreeable  effect  of  the 
remedy  observed,  and  that  was  a  stran- 
gury of  temporary  character,  after  15 
drachms  had  been  given  in  twenty-four 
hours,  to  a  boy  4  years  of  age.  Kellogg 
(Med.  and  Surg.  Reporter,  July  9,  '92). 

Hydroehlorate  of  ammonia  is  valuable 
(1)  as  a  heart-stimulant,  (2)  in  relieving 
the  spasm  and  ccdema  of  the  glottis,  and 
(3)  in  softening  the  membrane.  Hub- 
bard (Med.  Rec,  Apr.  11,  '91). 

The  following  formula,  suggested  by 
Joseph  Holt,  of  New  Orleans,  has  been 
tried  many  times  with  the  happiest  re- 
sults:— 

R  Chloralis,  7  grains. 

Potassii  bromidi,  45  grains. 

Ammonii  bromidi,  30  grains. 

Aquse  cinnamomi,  2  ounces. 
M.     Sig. :    Teaspoonful,  and  repeat  in 
twenty  minutes  if  not  relieved. 

This  is  intended  for  a  child  about  5 
years  old.  For  younger  children  the  dose 
is  slightly  diminished.  This  prescription 
is  of  no  benefit  in  true,  or  membranous, 
croup,  when  diphtheria  antito.xin  must 
be  promptly  used.  H.  E.  Slack  (Jour. 
Amer.  Med.  Assoc,  May  C,  '99). 

Floyd  M.  Crandall, 

New  York. 

CROUPOUS  PNEUMONIA.     See 

Pneumonia. 

CUBEB. — Cubeba  officinalis  is  a  climb- 
ing perennial  found  generally'  through- 
out the  East  Indies,  and  abundant  in 
Java,  Batavia,  Saranak,  New  Guinea, 
Nepane,  and  the  Isle  of  France.  The 
fruit  is  the  part  emploA'ed  medicinally, 
and  appears  as  partly  shriveled  or 
wrinkled  berries,  owing  to  the  fact  they 
are  gathered  prior  to  ripening,  bearing 
considerable  resemblance  in  point  of  size, 
and  also  in  color,  to  black  pepper  and 
piments,  but  less  globose  and  furnished 
with  a  stout  stalk  that  is  continuous  with 
raised  veins  that  run  over  the  surface  of 
the  fruit  and  embrace  it  like  net-work. 


The  shell  is  hard,  and  contains  a  single 
loose  seed  covered  with  a  blackish  coat, 
but  internally  white  and  oleaginous  with 
pungent  aromatic  taste  and  a  peculiar 
aromatic  odor  that,  once  experienced, 
will  never  be  forgotten.  When  reduced 
to  powder  the  general  tint  is  chocolate- 
brown,  becoming  darker  with  age,  and 
an  oily  look  and  feeling.  A  good  quality 
freshly  ground  yields  about  l-t  per  cent, 
of  volatile  oil,  which,  however,  is  readily 
dissipated  with  age;  little  powdered  cu- 
bebs  as  found  in  shops  will  yield  more 
than  4  per  cent,  of  oil,  and  much  of  it  is 
worthless. 

Oil  of  cubebs  is  a  greenish-yellow  fluid 
possessed  of  a  warm,  camphoraceous  taste 
and  aromatic  cubeb  odor,  soluble  in  al- 
cohol, ether,  and  chloroform;  it  yields 
cubebic  acid;  cubeb-camphor,  or  stere- 
opten;  and  cubebin. 

Cubebic  acid  is  a  white,  wax-like  mass 
that,  by  exposure,  acquires  a  brown  hue 
and  resin-like  consistency;  soluble  in  al- 
cohol, ether,  chloroform,  and  alkaline  so- 
lutions. 

Oleoresin  cubeb  is  identical  with  the 
preparation  formerh'  known  as  ethereal 
extract. 

Cubeb-resin  is  an  amorphous  body  sol- 
uble in  alcohol  and  alkalies.  Cubebin,  at 
one  time  supposed  to  be  identical  with 
piperine,  is  a  precipitate  most  easily  ob- 
tained from  the  oleo-resin  (ethereal  ex- 
tract); it  is  white,  crystalline,  inodorous, 
and  highly  bitter,  especially  if  dissolved 
in  alcohol.  Like  cubeb-camphor,  it  is 
therapeutically  inert. 

Preparations  and  Doses. — Cubeb  ex- 
tract, ethereal  (oleoresin),  5  to  30  minims. 

Cubeb  extract,  fluid,  10  to  60  minims. 

Cubeb  extract,  solid,  2  to  8  grains. 

Cubeb  infusion  (-l  to  16),  1  to  2  ounces 

Cubeb-oil,  10  to  30  minims. 

Cubeb,  powdered,  10  to  60  grains. 

Cubeb  tincture,  15  to  120  minims. 


360 


CUBEB. 


CURARA. 


Cubeb  troches,  1  to  5;  each  should 
contain  3  grains  of  powdered  cubebs  with 
fruit-paste. 

Cubebic  acid,  5  to  10  grains. 

Physiological  Action  and  Therapeu- 
tics.— Cubeb  is  stimulant,  aromatic,  sto- 
machic, diuretic,  expectorant,  antiseptic, 
and  mild  diaphoretic;  cubebic  acid  is 
markedly  antiblennorrhagic.  Appetite 
and  digestion  are  generally  increased  and 
improved  by  cubeb  preparations;  but  too 
large  doses  or  too  prolonged  use  are  apt 
to  induce  gastro-intestinal  irritation, 
and,  while  exerting  a  laxative  action,  oc- 
casions a  sensation  of  heat  and  discom- 
fort in  the  rectum;  there  appears  to  be 
also  a  selective  action  for  mucous  mem- 
brane, more  particularly  that  of  the  blad- 
der and  urethra.  In  very  large  doses 
(150  to  500  grains  of  powder)  consider- 
able febrile  action  is  observed,  along  with 
griping,  drastic  purging,  headache,  net- 
tle-like eruption,  and,  rarely,  paralysis. 

Cubeb,  like  other  peppers,  readily  en- 
ters into  the  circulation  and  increases  the 
force  and  frequency  of  the  heart's  action. 
It  is  absorbed  and  eliminated  with  con- 
siderable rapidity,  chiefly  by  the  kidneys, 
but  also  through  the  skin  and  bronchial 
mucous  membrane. 

Catarrhal  Disorders. — In  maladies 
of  a  catarrhal  character,  such  as  gonor- 
rhoea, gleet,  leucorrhoea,  vaginitis,  in- 
fantile enuresis,  chronic  inflammation  of 
bladder  and  prostate,  chronic  bronchitis 
and  other  pulmonary  afPections,  it  is  of 
great  value,  and  much  of  the  ill  repute 
that  accrues  to  the  drug  is  due  to  the 
dispensing  of  inert  preparations  and  er- 
roneous methods  of  application.  As  an 
example,  the  powder  of  cubeb  is  often 
recommended  in  such  disorders  as  hay 
fever,  chronic  rhinitis,  etc.,  in  which 
local  hyperaesthesia  is  an  active  factor. 
Such  a  use  of  the  remedy  serves  only  to 
discredit  it. 


Considerable  benefit  sometimes  follows 
its  use,  however,  when  eubeb-leaves  are 
smoked  in  cigarettes  in  disorders  of  the 
respiratory  tract  characterized  by  free 
secretion.  A  spray  of  lanolin  more  or 
less  strongly  charged  with  cubeb,  accord- 
ing to  the  intensity  of  the  trouble  pres- 
ent, is  also  of  marked  value  in  catarrhal 
inflammations  of  the  nasal  and  pharyn- 
geal cavities.  The  troches  of  cubeb,  1 
bean,  slowly  dissolved  in  the  mouth  every 
two  hours,  serve  to  maintain  the  benefi- 
cial action  of  the  remedy. 

CURARA.  —  This  substance — known 
also  as  curare,  woorari,  ourari,  urari, 
woorara,  wourali,  and  ourali,  though  it 
has  been  before  the  medical  profession 
for  more  than  half  a  century — is  prac- 
tically unknown  as  to  its  source  and 
composition.  There  is  considerable  evi- 
dence to  show  that  it  is  derived  in  part 
from  two  or  more  trees  of  the  strych- 
nine group,  from  the  Menispermum  coc- 
culus  (Cocculus  Indicus),  and  various  un- 
known plants.  It  comes  chiefly  from  the 
valley  of  the  Orinoco, — Brazil,  British 
and  French  Guiana,  Venezuela,  and  Co- 
lombia,— where  it  serves  certain  savage 
tribes  as  an  arrow-poison.  It  is  by  no 
means  a  stable  or  uniform  substance; 
some  appear  to  have  mingled  with  it  the 
poisonous  principle  of  Jatropha  (Mani- 
hot  utilissima),  known  as  ohi  or  dbiah 
poison  in  the  West  Indies,  while  that 
from  Colombia  is  of  lighter  color,  appear- 
ing as  a  yellowish-brown,  amorphous, 
deliquescent  powder.  Brazilian  and 
Guianian  curare  is  a  blackish,  intensely 
bitter,  hygroscopic  mass  of  resinous  ap- 
pearance. Both  are  soluble  in  dilute 
alcohol  to  the  amount  of  70  per  cent, 
and  in  the  water  to  75  or  85  per  cent., 
Imt  insoluble  in  ether.  Two  alkaloids 
liave  been  segregated  known  as  "cura- 
rinc"  and  "curine." 


CURARA.    PHYSIOLOGICAL  ACTION. 


361 


The  Indians  of  the  Orinoco  prepare 
two  kinds  of  curara:  one  a  relatively- 
mild  poison  used  in  the  chase,  its  chief 
source  being  Strychnos  gubleri;  the 
other  much  stronger,  a  war  poison,  from 
the  S.  toJfifera.  Planchon  (Provincial 
Med.  Jour.,  July,  'SS). 
Preparations  and  Doses. — Curara,  Vao 
to  Vj  grain. 

Curarine,  V200  to  Vso  grain. 
Curarine  sulphate,  ^/joo  to  ^/loo  grain. 
Curine,  uncertain. 

Physiological  Action. — Neither  curara 
nor  its  alkaloids  are  ever  employed  ex- 
cept endermically  (rarely)  or  hypoder- 
mically,  since  it  is  held  that  all  are  de- 
composed in  the  stomach  and  rendered 
practically  inert.  The  latter  is  not  true, 
however;  but  the  process  of  absorption 
is  extremely  slow;  but  when  employed 
subcutaneously  it  is  rapidly  absorbed. 
Elimination  is  rapid,  chiefly  by  the  kid- 
neys, causing  sugar  to  appear  in  the 
urine,  and  partly  with  the  faeces;  per- 
spiration, saliva,  nasal  mucus,  and  tears, 
though  greatly  increased,  do  not  seem  to 
share  in  the  eliminative  process. 

It  is  not  absorbed  by  intact  integu- 
ments, but  is  absorbed  (though  with  dif- 
ficulty) by  mucous  membrane.  When 
introduced  into  the  system  and  brought 
in  contact  with  the  systemic  tissues,  the 
drug  develops  identical  biological  effects 
in  dogs,  cats,  rabbits,  pigeons,  amphib- 
ians, batrachians,  reptiles,  fishes,  crus- 
taceans, insects,  and  amcebas.  According 
to  the  duration  of  its  contact  with 
various  organs  and  tissues,  curara  may 
paralyze  either  the  central  nervous  sys- 
tem or  terminations  of  motor  nerves  of 
any  muscular  structure  (including  the 
heart)  and  of  the  vagi;  this  least  rap- 
idly in  dogs  and  rabbits.  In  mammals 
generally  it  causes  death  by  paralyzing 
the  respiratory  centres,  but  not  the  pe- 
ripheral respiratory  nerves.  The  proxi- 
mate cause  of  tlie  biological  effects  of 
curai'a  is,  probably,  constituted  by  the 
drug  inducing  some  alterations  in  the 
protoplasm  of  both  nervous  and  muscular 
structures,  though  to  a  different  extent, 


and  not  simultaneously.  Dogiel  and 
Nikolski  (Medit.  Oboz.,  No.  3,  '90;  Med. 
Chron.,  June,  '90). 

Curarine  paralyzes  the  motor  nerve- 
endings,  but  has  no  eflect  on  sensory 
nerves.  The  irregularity  and  the  early 
depression  of  the  reflexes  are  not  due 
to  an  action  on  the  spinal  cord  or  the 
sensory  nerves,  but  to  an  inhibitory  in- 
fluence exercised  upon  the  cord  by  a 
stimulation  of  the  higher  centres.  The 
alkaloid  likewise  exerts  a  tetanic  action 
on  the  cord,  but  the  reason  why  it  docs 
not  induce  tetanic  spasm,  in  the  great 
majority  of  cases,  when  given  hypo- 
dermically  is  because  the  circulatory 
changes  produced  are  such  as  to  prevent 
the  diaig  from  having  access  to  the  cord, 
and  because  these  changes  of  themselves 
produce  spinal  paralysis.  With  larger 
doses  there  is  dilatation  of  the  abdominal 
vessels,  and  hence  accumulation  of  blood, 
little  or  nothing  of  this  fl\iid  entering 
the  empty  ventricle,  notwithstanding 
that  the  heart  may  continue  to  beat. 
Curarine  causes  an  almost  immediate 
fall  of  blood-pressure  in  mammals;  it 
occurs  even  after  section  of  vagi,  after 
a  paralyzing  dose  of  atropine,  after 
division  of  all  the  cardiac  nerves,  after 
section  of  the  spinal  cord,  and  after 
paralysis  of  the  central  reflexes  by 
urethane.  The  cause,  therefore,  of  the 
fall  of  pressure  must  be  due  to  a  direct 
action  upon  the  peripheral  nerves  or 
upon  the  muscles  of  the  blood-vessel 
walls.  It  was  found,  however,  that  when 
an  injection  of  barium  was  made  into 
the  circulation  a  rise  of  pressure  was 
produced,  while,  on  the  other  hand,  no 
such  action  was  effected  by  stimulation 
of  the  peripheral  nerves.  Again,  the 
vasomotor  centre  was  found  to  be  active 
by  the  appearance  of  the  "Traube- 
Hering"  curves  during  the  cessation  of 
respiration  by  the  action  of  the  drug. 
This  evidently  proves  that  curarine 
causes  a  fall  of  pressure  solely  by  a 
paralyzing  influence  exercised  on  the 
vasomotor  nerves.  The  inhibition  of  the 
vagi  is  destroyed  by  curarine  easily  in 
cats,  less  so  in  dogs,  and  with  diflSculty 
in  rabbits.  Small  doses  in  a  healthy 
rabbit  caused  the  appearance  of  albu- 
min, blood-pigment,  and  blood  in  urine. 


362 


CURAEA.     POISONING.     TREATMENT.     THERAPEUTICS. 


An  infusion  of  the  bark  of  the  Stri/eli- 
nos  toxifera  caused  the  same  effects  as 
curara  and  curarine. 

Curine  has  no  apparent  effect  on  motor 
nerves,  but  acts  on  the  heart  like  vera- 
trine  or  drugs  of  the  digitalis  group. 
Tillie  (Med.  Chron.,  Mar.,  "91). 

In  poisoning  by  curara  muscular  power 
is  notably  diminished.'  Grghant  and 
Quinquaud  (La  Sem.  Med.,  Apr.  22,  '91). 

The  action  of  the  drug  on  muscle- 
tissue  is  a  factor  in  the  general  paralysis 
induced.  According  to  Keichert,  doses 
insufficient  to  cause  motor  paralysis  may 
increase  the  temperature,  or  primarily 
increase  and  secondarily  diminish  it. 
The  use  of  quantities  just  sufficient  to 
aholish  voluntary  motion  act  differently 
in  different  animals:  the  temperature 
from  the  first  may  be  increased  or  de- 
creased, or  primarily  increased  and  sec- 
ondarily decreased,  or  primarily  dimin- 
ished and  accordingly  increased;  gener- 
ally there  occurs  a  notable  diminution  or 
a  decided  increase,  the  former  effect  pre- 
dominating. 

A  variety  of  curara  from  Colombia 
causes  absolute  paralysis  of  the  muscle 
of  the  heart,  the  respiration  continuing; 
and  absolute  paralysis  and  rigidity  of 
tlie  skeletal  muscles  at  a  much  earlier 
period  than  happens  in  the  case  of  an 
animal  whose  circulation  has  been  arti- 
ficially arrested;  also  exemption  of  the 
motor  nerves  from  paralysis  until  after 
death  and  until  the  muscles  show  signs 
of  poisoning.  In  an  experiment  upon  a 
rabbit  the  effects  produced  were  mark- 
edly different  from  those  caused  by  ordi- 
nary curara.  With  the  new  drug  the 
motor  weakness  only  appeared  near 
death;  but  there  was  marked  action  on 
the  heart,  as  well  as  an  early  total  pa- 
ralysis of  muscles  and  onset  of  rigidity. 
Tillie  (Jour.  Anatomy  and  Physiology, 
Oct.,  '93). 

Medicinal  doses  render  the  pulse  more 
full  and  exceedingly  rapid, — there  is 
marked  dilatation  of  the  blood-vessels  of 
the  skin  and  the  various  glands, — and 
the  blood-pressure,  though  little  affected 


by  small  doses,  is  decidedly  lowered  by 
large  ones.     The  action  on  the  circula- 
tion is  due  to  diminislred  inhibition  on 
the  heart,  owing  to  paralysis  of  the  ends 
of  the  vagi,  while  the  accelerator  nerves 
are  stimulated.    It  elevates  temperature. 
Immoderate    doses    cause   great   mus- 
cular weakness  and  paralj'sis  of  all  the 
voluntary    muscles.      The    ends    of    the 
motor  and  sensory  nerves  are  paralyzed, 
the  former  being  soonest  aft'eetcd.     Be- 
yond a  slightly-diminished  contractility, 
the  voluntary  muscles  are  but  little  in- 
fluenced.    The  spinal  cord  may  be  par- 
alyzed   by    toxic    doses,    although    the 
brain-centres    remain    unaffected    until 
carbonic-acid  narcosis  sets  in.    It  is  like- 
wise a  powerful  respiratory  depressant, 
paralyzing  the  ends  of  the  motor  nerves 
distributed  to  the  respiratory  muscles; 
if  the  doses  are  lethal,  the  paralysis  be- 
comes central,  finally  producing  death  by 
its   action    on   the   respiratory   muscles. 
Butler  ("Text-book  of  Mat.  Med.,  Ther., 
and  Phar.,"  '96). 
Poisoning  by  Curara. — In  poisoning 
the  movements  of  the  heart  are  greatly 
accelerated,  the  pulse  weak  and  dicrotic, 
the   temperature   high,   respiration   de- 
pressed; extreme  muscular  weakness  en- 
sues, with  inco-ordination  of  movements; 
urine  is  saccharine;  paralysis  of  extremi- 
ties and  respiratory  muscles  supervene, 
and  death  ensues  from  the  latter  cause. 
Treatment  of  Curara  Poisoning. — The 
treatment    of    the    poisoning    consists 
chiefly  of  artificial  respiration  and  the 
employment  of  tetanizing  agents,  such 
as  strychnine  and  picrotoxin.    Alcoholic 
stimulants  may  be  indicated.     Caffeine, 
atropine,  and  cliloral  are  sometimes  of 
benefit. 

Therapeutics. — Curara  is  more  em- 
ployed in  the  physiological  laboratory 
than  as  a  medicament  pure  and  simple, 
and  study  of  the  drug  on  therapeutic 
lines  has,  in  a  measure,  been  inhibited 
because  of  its  unreliable  composition;  so 
true  is  this  latter  that  the  caution  is  gen- 
erally given  that  before  any  one  sample 


CURARA. 


363 


is  employed  in  the  human  subject  its 
strength  should  first  be  tested  on  one  of 
the  lower  animals.  Merck,  however,  puts 
out  a  reliable  article:  one  that  is  care- 
fully tested  ere  it  is  offered  for  therapeu- 
tic purposes.  It  is  a  powerful  remedy 
for  good  when  employed  in  convulsive 
diseases,  such  as  hydrophobia,  traumatic 
tetanus,  and  epilepsy,  and  sometimes 
yields  good  results  in  paralysis  agitans, 
locomotor  ataxia,  nervous  debility,  and 
the  dyspepsia  of  emphysema. 

Case  of  a  boy,  aged  IG  years,  who  had 
suffered  with  epilepsy  since  infancy  and 
in  whom  the  attacks  occurred  at  inter- 
vals of  a  few  minutes.     After  all  other 
remedial   measures  had  been  exhausted 
Vio  grain  of  curara  was  injected  hypo- 
dermically,   when   the    attacks   recurred 
at  intervals  of  hours  instead  of  minutes. 
After  six  injections  of  curara,  at  five- 
day  intervals,  in  doses  of  Vio  or  V»  grain, 
complete   relief  was   had;    after   several 
months  no   return   of  the  epilepsy   was 
experienced.    Dobrorarow  (La  Sem.  MCd., 
June,  '04). 
It    would    seem,    from    Tillie's    re- 
searches, that  a  preparation  from   the 
bark  of  Strychnos  ioxifera  would  afford 
a  remedy  of  the  same  scope  as  curara, 
and  one,  moreover,  that  would  be  uni- 
form in  strength.     Used  judiciously,  it 
would  probably  be  a  valuable  addition 
to  the  list  of  antispasmodics,  one  espe- 
cially available  in  neuropathies. 

G.  Archie  Stockwell, 

New  York. 

CYST.  See  Surgical  Diseases  of 
THE  Skin. 

CYSTITIS.— Lat.,  from  Gr.,  xvoric,, 
the  bladder,  and   (T(^,  inflammation. 

Definition. — Inflammation  of  the  uri- 
nary bladder,  involving  one  or  more  of  its 
four  coats:  mucous,  submucous,  mus- 
cular, and  serous. 

Varieties. — Cystitis  has  been  divided 


into  a  large  number  of  varieties,  the  sub- 
divisions being  based  upon  the  many 
etiological  and  pathological  features  of 
the  disease.  A  further  classification  of 
this  disease  into  the  acute,  the  subacute, 
and  the  chronic  is  dependent  upon  the 
intensity  of  the  symptoms  and  the  length 
of  time  of  their  existence  and  is  utilized 
in  this  article. 

Symptoms. — In  acute  cystitis  the  com- 
mencement differs  somewhat  according 
to  the  determining  cause.  When  trau- 
matic, it  may  be  ushered  in  with  rigors  or 
marked  chill  succeeded  by  burning  pain 
in  the  bladder  and  glans  penis,  etc.  In 
other  instances,  and  when  from  other 
causes,  it  is  announced  by  a  feeling  of 
uneasiness,  which  is  located  in  the  per- 
ineum. There  is  increased  frequency  of 
urination  and  spasmodic  pain  during 
micturition  and  more  or  less  fever.  Usu- 
ally the  fever  is  absent,  but,  in  the  severe 
forms,  there  is  moderate  fever  and  some- 
times, in  the  pseudomembranous  variety, 
quite  high  fever.  Usually  the  tempera- 
ture in  cases  of  fever  range  from  100° 
to  102°  F.,  though  it  may  be  higher. 
These  constitute  the  ordinary  s)'mptoms. 
Pressure  upon  the  bladder  is  intolerable. 
The  urine  may  be  blood-tinged  through- 
out the  attack,  but  more  usually  is  re- 
placed soon  by  pus,  and  becomes  am- 
moniacal.  Acute  retention  is  common. 
If  complete  retention  ensues,  the  bladder 
gradually  becomes  more  and  more  dis- 
tended and  can  be  felt  as  a  rounded 
tumor,  giving  a  dull  sound  on  percussion, 
rising  higher  and  higher  above  the  pubes. 
The  tenesmus  vesicae,  or  the  feeling  that 
the  patient  has  not  emptied  the  bladder 
after  the  viscus  has  been  emptied,  may 
occasionally  be  communicated  to  the 
rectum;  and,  in  point  of  fact,  all  of  the 
pelvic  organs  may  participate  in  the  pain- 
ful and  distressing  sensation. 

The  frequent  desire  to  pass  water  va- 


364 


CYSTITIS.     SYJiIPTOMS. 


lies  in  intensity.  It  may  be  every  few 
moments  or  almost  incessant;  several 
times  an  hour  or  once  in  a  conple  of 
hours. 

The  constitutional  disturbance,  when 
the  disease  is  of  grave  form,  is  very 
marked,  as  indicated  by  a  frequent  pulse, 
thirst,  headache,  and  nausea,  with  great 
restlessness  and  mental  anxiety.  When 
cystitis  progresses  toward  a  fatal  termi- 
nation, portions  of  the  walls  of  the  blad- 
der may  suppurate  or  even  slough,  and 
ma}'  be  discharged  in  stringy  fragments; 
the  urine  emits  a  vile  odor,  from  the 
products  of  its  own  decomposition  and 
the  gases  resulting  from  the  dead  mucous 
and  submucous  tissue  which  it  contains; 
the  patient  is  harassed  with  hiccough; 
the  pulse  becomes  very  small  and  fre- 
quent, the  tongue  dry  and  hard,  streaked 
with  a  dark  coat;  the  strength  rapidly 
fails;  the  secretion  of  the  kidneys  di- 
minishes or  is  entirely  suspended;  the 
countenance  becomes  sunken  and  cadav- 
erous, the  extremities  cold,  the  surface 
moistened  with  perspiration,  from  which 
emanates  the  odor  of  urine,  and  the  pa- 
tient at  last  passes  into  a  state  of  pro- 
found stupor,  from  which  he  never  awak- 
ens.   (D.  Hayes  Agnew.) 

In  chronic  cystitis  the  symptoms  are 
mainly  those  of  the  acute  variety,  but  in 
a  milder  degree.  Only  slight  fever  is 
present,  but  the  combination  of  pain  and 
other  distress  rapidly  undermines  the 
general  health. 

Case  of  cystitis  without  symptoms. 
The  urine  was  pale,  had  a  specific  grav- 
ity of  1018,  and  contained  much  albumin 
and  some  leucocytes,  with  epithelial 
and  granular  casts.  There  was  no 
uraemia.  At  the  autopsy  was  found 
clironic  cystitis,  especially  around  the 
trigone.  Martha  Wollstoin  (Med.  Rcc, 
Jan.  23,  '97). 
The  urine  is  turbid,  alkaline,  and 
contains  much  mucus  and  pus,  which 


forms  a  tenacious  clot  at  the  bot- 
tom of  the  retaining  vessel.  'While  the 
urine  is  usually  alkaline,  it  occasion- 
ally is  faintly  acid,  but,  if  so,  promptly 
becomes  alkaline,  due  to  the  formation 
of  ammonium  carbonate  out  of  the  nor- 
mal urea,  the  probable  result  of  the  oper- 
ation of  bacteria. 

There  seems  very  little  doubt  that  we 
have  to  recognize  the  existence  of  two 
distinct  types  of  cystitis:  one  associated 
with  acid  and  the  other  with  alkaline 
urine.  In  the  latter  some  of  the  or- 
ganisms capable  of  decomposing  urea 
and  liberating  ammonia  are  present, 
e.g.,  the  diplococcus  ureee  liquefaciens, 
the  proteus  Hauser,  the  bacillus  pyo- 
eyaneus,  etc.,  with  or  without  the 
bacillus  coli  communis;  in  the  acid 
forms  of  cystitis  tlie  latter  organism  is 
alone  present.  The  former  type  has 
long  been  recognized  and  its  characters 
noted;  but  practitioners  are  not  so  fre- 
quentlj'  on  the  lookout  for  cystitis  with 
acid  urine.  Melchior  (Centralb.  f.  d. 
Krankh.  d.  Harn-  u.  Sexual-organe,  May, 
'97). 

In  a  case  of  cystitis  the  symptoms — 
pain,  pus  in  the  urine,  and  frequency  of 
urination — must  be  present,  and  they 
must  emanate  from  the  bladder.  They 
may  come  from  other  causes,  singly  or 
combined.  If  singly,  the  disease  is  not 
cystitis;  if  combined,  tliey  may  result 
from  two  or  more  diseases.  In  tlie  be- 
ginning of  acute  cystitis  there  is  often 
fever,  depression,  nausea,  loss  of  appetite, 
constipation,  etc.  Htematuria  is  also 
often  present.  In  chronic  cystitis  the 
urine  is  generally  light  in  color,  alkaline, 
of  a  lowered  specific  gravity,  containing 
a  slight  amount  of  albumin,  perhaps 
some  blood,  and  pus  in  abundance. 
When  allowed  to  settle,  pus  forms  a 
more  or  less  dense  deposit  on  the  bottom 
of  the  glass,  above  which  there  is  a 
cloud  of  muco-pus.  Bladder-epithelium 
is  found,  especially  in  the  forms  wliere 
ulceration  is  present.  In  all  cases  cer- 
tain microbes  of  suppuration  are  present. 
Guitf'ras  (N.  Y.  Med.  Jour.,  Mar.  19, 
'98). 

Cystitis    pai)illoniatosa    occurs    in    the 


CYSTITIS.    DIAGNOSIS. 


365 


female  as  a  form  of  chronic  cystitis,  and 
may  present  the  clinical  picture  either 
of  the  catarrhal  or  of  the  suppurative 
form.  Its  symptoms  are  frequency  of 
urination,  accompanied  by  more  or  less 
pain,  and  tenesmus,  the  urine  passed  be- 
ing clear  or  turbid.  Bleeding  does  not 
occur  spontaneously,  although  it  may 
follow  instrumentation.  Its  scat  is  at 
the  trigone,  which  it  usually  covers,  and 
it  may  extend  over  into  the  urethra, 
from  which  at  times  it  appears  to  start. 
Its  villi,  or  papilla?,  spring  from  an  in- 
llanicd  base,  and  are  discrete.  Frederic 
Bierliofl'  (Med.  News,  May  26,  1900). 

The  greater  alkalinity  thus  resulting 
reacts  npon  the  pus  and  converts  it  into 
a  glairy  matter  similar  to  mucus,  thus 
further  increasing  the  difficulties  of  uri- 
nation.   (Tyson.) 

Diagnosis. — This  is  usually  easy.  Yet 
there  sometimes  occur  mild  forms  which 
it  is  difficult  to  differentiate  from  mild 
degrees  of  interstitial  nephritis,  while  it 
not  very  rarely  happens  that  these  two 
conditions  are  associated.  In  contracted 
kidney  there  are  sometimes  many  leuco- 
cytes also.  The  presence  of  hyaline  casts, 
even  when  scanty,  points  to  nephri- 
tis, while  hypertrophy  of  the  left  ven- 
tricle and  increased  arterial  tension  settle 
the  question.  Still  more  emphatic  is  the 
diagnosis  if  there  be  retinitis  albumi- 
nurica  (Tyson).  According  to  the  same 
authority,  the  question  whether  there 
is  pyelitis,  separate  or  associated  with 
cystitis,  is  still  more  difficult  to  deter- 
mine. Catheterism  of  the  ureter  by  the 
method  of  Howard  A.  Kelly,  if  a  possible 
procedure  in  the  given  case,  would,  of 
course,  clear  iip  all  doubt.  Tyson  places 
most  reliance  on  the  symptom  of  tender- 
ness in  the  region  of  the  kidney. 

TTsually  the  symptoms  of  the  diseases 
under  discussion  leave  scarcely  any  room 
for  doubt;  the  sense  of  uneasiness  in  the 
neighborhood  of  the  bladder,  the  fre- 
quent desire  to  empty  the  bladder,  and 


the  thick,  purulent  urine,  taken  in  con- 
junction with  microscopical  examina- 
tions, will  render  the  diagnosis  certain. 
It  is  very  important  to  ascertain  whether 
the  cystitis  is  idiopathic  or  the  result  of 
disease  of  the  urethra,  prostate,  etc.,  and 
especially  whether  a  foreign  body,  such 
as  a  calculus,  is  present  in  the  bladder. 
It  is  also  important  to  differentiate  spasm 
of  the  bladder,  which  is  also  attended  by 
pain  and  frequent  micturition;  but  the 
quality  and  the  daily  quantity  of  the 
urine  passed  remain  normal. 

There  is  a  scries  of  diseases  with  blad- 
der manifestations  in  which  no  patho- 
logical condition  exists  in  the  bladder 
usually  diagnosed  as  cystitis.  The  blad- 
der symptoms  in  such  are  the  result  of 
nervous  reflexes,  principally  from  an 
affected  posterior  urethra,  but  they  may 
also  come  from  the  anterior  urethra, 
from  the  ureter,  and  even  from  the  kid- 
ney. The  diagnosis  is  often  extremely 
diflicult  and  depends  finally  on  careful 
local  examination.  In  cases  of  false 
cystitis  the  symptoms  are  always  ag- 
gravated by  intravesical  medication. 
Gu6pin  and  Grandcourt  (Med.  Rec, 
Sept.  18,  '07). 

Differential  diagnosis  between  cystitis 
and  pyelitis:  1.  An  alkaline  reaction  is 
not  found  with  uncomplicated  pyelitis. 
2.  The  limit  of  albumin  in  the  urine  even 
with  severest  cystitis  is  0.1  per  cent, 
(maximum,  0.15).  3.  If  nearly  all  the 
pus-coi-puscles  are  crenatcd,  the  condition 
is  pyelitis.  4.  If  the  red  corpuscles  pres- 
ent are  chemically  or  morphologically  de- 
composed, provided  the  ha;raorrhage  is 
only  microscopic  and  there  is  no  vesical 
tumor,  pyelitis  exists.  5.  The  character- 
istic symptom  for  diagnosis  is  the  rela- 
tion of  the  albumin-content,  which  is 
from  2  to  2 '/:  or  even  3  times  greater 
in  pyelitis  than  in  cystitis. 

Esbnch's  albuminometer  is  valuable  in 
determining    the    amount    of    albumin. 
George  Rosenfeld   (Berliner  klin.  Woch., 
July  25,  '9S). 
In  polyuria  also  the  urine  is  voided 
frequentlj-,  but  without  any  pain  or  pur- 
ulent sediment.    (Lebert.) 


366 


CYSTITIS.    ETIOLOGY. 


Etiolo^. — Men  are  more  liable  than 
women  to  vesical  catarrh.  Traumatism 
is  a  frequent  cause;  injuries,  such  as 
blows  and  pelvic  fractures,  more  particu- 
larly of  the  pubic  bone,  though  both  are 
rather  rare  conditions.  Operations  of 
lithotomy,  lithotrity,  catheterism,  injec- 
tions; pressure,  as  in  prolonged  and  in- 
strumental labors,  in  which  class  of  cases 
gangrene  of  the  walls  of  the  viscus  has 
been  known  to  ensue,  followed  by  a  large 
vesico-vaginal  fistula.  Mechanical  irrita- 
tion of  foreign  substances  in  the  bladder, 
such  as  calculi;  the  poisonous  effect  of 
certain  drugs,  as  the  chemical  action  of 
cantharides  and  some  of  the  mineral 
poisons;  the  action  of  the  urine  itself, 
retained  and  decomposed,  as  in  stricture 
and  in  prostatic  enlargement;  inflam- 
mations of  neighboring  parts,  as  the  kid- 
neys, prostate,  rectum,  urethra,  and, 
when  so  developed,  it  is  in  consequence  of 
a  pre-existing  gonorrhoea,  a  prostatitis, 
or  the  presence  of  a  stricture, — urethral 
or  rectal, — etc.;  acute  cystitis  sometimes 
develops  secondarily  in  the  course  of  the 
infectious  diseases. 

Frequency  of  cystitis  in  the  course  of 
infectious  diseases  attacking  nursing 
children.  Tliirty  cases  observed  all  un- 
der one  year  of  age;  all  girls,  suffering 
from  broncho-pneumonia,  acute  gastro- 
enteritis, meningitis,  etc.,  which  nearly 
always  ended  fatally.  The  etiology  is 
nearly  always  dependent  upon  retention, 
the  result  of  the  grave  general  disease. 
Finkelstein  (Revue  Prat.  d'Obstet.  et  de 
GynC'C.,  July,  '97). 

Regarding  the  bacterial  origin  of 
cystitis,  James  Tyson  states  that  the 
question  of  whether  the  obstructive 
causes  enumerated  are  of  themselves  suf- 
ficient, or  whether  they  may  simply  sup- 
ply the  conditions  favorable  to  the  opera- 
tion of  bacteria,  may  be  considered  un- 
settled at  the  present  day.  J.  W.  White 
and  Edward  Martin,  on  the  other  hand, 


hold  that  all  cases  of  cystitis  are  un- 
doubtedly due  to  the  presence  of  patho- 
genic organisms.  Among  the  organisms 
capable  of  producing  inflammation  may 
be  mentioned  the  streptococcus  pyogenes, 
staphylococcus  pyogenes  aureus,  diplo- 
coccus,  bacterium  coli  commune,  tuber- 
cle bacilli,  etc. 

The  bacterium  coli  is  one  of  the  most 
common  germs  found  in  cystitis.  It  may 
enter  the  bladder  by  passing  through 
the  urethra,  or  from  the  neighborhood 
through  the  vesical  wall;  but  it  may 
also  enter  the  blood-vessels  and  pass  out 
again  through  the  kidneys  when  the 
latter  are  in  a  morbid  state.  Thus  this 
bacterium  may  be  a  cause  of  cystitis 
when  predisposing  conditions  exist.  Of 
37  cases  of  cystitis  examined,  the  colon 
bacillus  was  found  in  13  (12  times  soli- 
tary); diplocoeous  urece  liquefaciens  11 
times  (9  times  solitary) ;  proteus  Hauser 
5  times  (3  times  solitary),  and  staphy- 
lococcus pyogenes  4  times  (3  times  soli- 
tary). M.  Melchior  (Ugeskrift  for  Liiger, 
'97). 

Analysis  of  forty-six  cases.  Conclusion 
that  cystitis  (with  certain  rare  excep- 
tions of  chemical  or  toxic  origin)  is 
always  due  to  micro-organisms,  the  bac- 
terium eoli  commune  being  the  most 
common.  The  mucosa  of  the  bladder, 
however,  must  previously  be  in  a  condi- 
tion favorable  to  infection.  Kargcr 
(Centralb.  f.  Gynilk.,  No.  2,  '98). 

There  is  no  better  method  of  causing 
cystitis  than  the  attempt  to  perform 
catheterization  without  full  antiseptic 
precautions.  The  catheter  should  never 
be  passed  without  tlie  exposure  and 
cleansing  of  the  meatus  urinarius.  The 
cleansing  should  be  done  with  bichloride 
solution  1  to  1000,  and  a  sterilized  cath- 
eter passed  under^  the  guidance  of  the 
eye.  As  a  lubricant,  the  best  is  boro- 
glyceride  solution.  Noble  (Gaillard's 
Med.  Jour.,  Apr.,  '98). 

In  cystitis  coming  on  after  catheterism 
in  women  it  seema  that  the  cause  of  tlie 
cystitis  is  injuries  produced  in  passing 
the  catheter,  rather  tluui  the  use  of  a 
dirty  one.  Walker  (N.  Y.  Med.  Jour., 
Mar.  19,  '98). 


CYSTITIS.    PATHOLOGY. 


367 


Cystitis  is  always  caused  by  the  pres- 
ence of  bacteria.  The  mere  presence  of 
bacteria  is  insuflicient  to  cause  cystitis; 
a  further  predisposing  cause  is  necessary. 
Under  favorable  conditions  any  pathog- 
enic organism  may  give  rise  to  cystitis. 
The  entrance  of  pathogenic  organisms 
into  the  bladder  may  be  through  the 
urethra,  through  tlie  ureter  from  an  in- 
fected kidney,  from  inflammatory  areas 
in  the  neighboring  parts,  and  through 
the  blood-stream  and  the  lymphatics. 
George  T.  llowland  (Med.  News,  July 
15,  '99). 

Kesults  of  experiments  on  one  hun- 
dred dogs:  A  lesion  of  the  rectum  in 
the  vicinity  of  the  prostate,  whetlier 
superficial  or  deep,  is  not  followed  by 
cystitis,  nor  are  intestinal  bacteria 
foxmd  in  tlie  urine  in  these  cases,  pro- 
vided the  bladder  at  the  outset  is  free 
from  disease,  and  provided  also  that  the 
rectal  lesion  is  not  followed  by  either 
general  systemic  infection  or  peritonitis. 
Serious  lesions  of  the  rectum  may  very 
readil}'  produce  general  infection,  how- 
ever. Omitting  cases  of  sepsis,  cystitis 
was  noted  in  only  one  of  many  cases, 
and  in  but  one  case  was  there  even  a 
transient  bacteriuria.  Microscopical  ex- 
amination showed  that,  following  the 
slightest  trauma  of  the  epithelial  sur- 
face of  the  rectum,  numerous  bacteria 
made  their  way  promptly  into  the  Ij'm- 
phatic  spaces  of  the  tissue  surrounding 
the  rectum,  bladder,  prostate,  and  semi- 
nal vesicles.  If  the  bladder  be  injured 
by  retention  at  this  stage,  the  patho- 
genic germs  which  are  sojourning  in  the 
neighborhood  may  succeed  in  finding  en- 
trance and  may  thus  set  up  a  cystitis. 
Faltin  {Centralbl.  f.  d.  Krankh.  d.  Harn- 
u.  Sexualorganc,  Bd.  xii,  H.  0,  1902). 

The  urine  in  cystitis,  as  a  rule,  con- 
tains both  cocci  and  bacilli.  The  bac- 
teria found  in  cystitic  urine  include  the 
staphylococcus  aureus,  albus,  or  cit- 
reus;  the  micrococcus  aurcte,  sarcina 
urinte,  the  urobacillus  liquefacicns  sep- 
ticus,  tlie  streptococcus  pyogenes,  zo- 
ogleic  masses,  the  gonococcus,  colon 
bacillus,  the  bacillus  typhosus,  proteus 
vulgaris,  bacillus  tuberculosis,  and  the 
bacillus    dysenterieus     of    Shiga.     The 


causative  factors  of  cystitis  in  most 
cases  are  the  colon  bacillus,  the  difTer- 
ent  varieties  of  the  staphylococcus,  the 
streptococcus,  the  tubercle  bacillus,  and 
the  gonococcus.  R.  C.  Longfellow 
(.Jour.  Amcr.  Med.  Assoc,  Apr.  4,  1903). 

Pathology. — The  changes  which  are 
produced  by  cj'stitis  consist  in  increased 
vascularity  of  the  mucous  membrane;  its 
light-red  color  being  exchanged  for  one 
of  a  dark-crimson  hue  throughout,  deep- 
ening to  purple  or  even  black  about  the 
neck  of  the  bladder;  or  the  mucous 
membrane  may  be  ecchymosed,  and  in 
places  necrotic,  and  the  muscular  layer 
may  be  exposed.  Iloemorrhages  may  oc- 
cur from  bursting  veins  or  separating 
sloughs;  or  perforation  may  occur  into 
the  surrounding  tissues  or  into  the  peri- 
toneal cavity.  Peritonitis  may  arise  ^vith- 
out  actual  perforation  (John  B.  Eoberts). 

In  the  more  chronic  cases  the  epithe- 
lium desquamates  vary  rapidly;  mucus 
at  first  and  then  pus  is  poured  out  in 
large  quantity.  The  urine  soon  becomes 
alkaline  and  is  putrescent.  Blood  is  fre- 
quently present.  Decomposition  precipi- 
tates the  salts  of  the  urine  and  calculi 
are  found  in  the  bladder  or  a  calcareous 
deposit  occurs  upon  the  walls  of  that 
viscus.  Wien  the  disease  has  been  of 
long  duration  the  muscular  wall  becomes 
either  hypertrophied  and  contracted,  or 
its  fasciculi  become  irregularly  stretched 
apart  while  the  mucous  membrane  sinks 
into  the  intervals,  giving  rise  to  the  con- 
dition known  as  sacculated,  or  ribbed, 
bladder.  These  depressions  or  sacs  may 
become  large  and  retain  decomposed 
urine,  act  as  receptacles  for  calculi,  or 
perforate  and  give  rise  to  peritonitis  or 
perivesical  abscess.  The  ureters  and  kid- 
neys soon  become  involved,  and  add  ma- 
terially to  the  serious  nature  of  the  case. 
The  commonest  cause  of  infection  of 
the  female  urinary  tract  is  the  bacil- 
lus  coli   communis,   which   a   studv    of 


368 


CYSTITIS.    PKOGNOSIS.    TREATMENT. 


the  cases  of  acute  cystitis  definitely 
proves  can  and  does  in  a  large  number 
of  cases  set  up  a  true  infection  without 
the  aid  of  any  other  micro-organism. 
Marked  variations  are  seen  in  the 
^•irulenee  of  this  micro-organism  and  in 
its  pyogenic  properties.  Other  micro- 
organisms frequently  found  are  the 
tubercle  bacillus,  various  staphylococci, 
and  the  bacillus  proteus  vulgaris,  while 
numerous  varieties  of  micro-organisms 
have  been  less  frequently  and  occasion- 
ally met  with,  as  the  baciUus  pyocy- 
aneus  and  typhoid  bacillus.  The  pro- 
portion of  eases  of  infection  due  to  the 
bacillus  coli  communis  is  greater  in 
women  than  in  men,  probably  due  to 
the  close  proximity  of  the  female  ure- 
thra to  the  anus.  Besides  the  entrance 
of  the  micro-organisms,  other  factors 
are  in  most  cases  essential  to  the  de- 
velopment of  a  cystitis;  the  chief  of 
these  factors  are  aneemia,  malnutrition, 
trauma  of  and  pressure  upon  the  blad- 
der, congestion  of  the  bladder,  and  re- 
tention of  urine.  In  cystitis  the  chief 
mode  of  infection  is  by  the  urethra, 
although  one  must  also  consider  as  pos- 
sibilities a  descending  ureteral  infection 
from  an  infected  kidney,  pyogenic 
metastasis  by  means  of  the  blood-  and 
lymph-  currents,  and  direct  transmis- 
sion of  the  micro-organisms  from  the 
intestinal  tract,  or  from  some  adjacent 
focus  of  infection.  In  pyelitis  and 
pyelonephritis  the  usual  modes  of  infec- 
tion are  along  the  ureter  from  an  in- 
fected bladder,  and  by  means  of  the 
blood-  and  lymph-  currents;  in  personal 
cases  these  modes  of  infection  were 
found  about  equally  represented.  In  the 
great  majority  of  cases  of  cystitis,  both 
acute  and  chronic,  and  in  the  majority 
of  cases  of  pyelitis  and  pyelonephritis, 
the  urine  is  acid.  In  cases  in  which  the 
urine  is  ammoniacal  the  infection  can 
be  produced  without  the  aid  of  any  of 
the  accessory  etiological  factors  men- 
tioned above,  the  irritation  of  the  am- 
moniacal urine  apparently  being  suffi- 
cient to  render  the  bladder  susceptible 
to  infection.  In  infections  of  the  kid- 
ney due  to  a  urea-decomposing  micro- 
organism a  stone  is  very  likely  to  be 
present   if  the   case   is   at   all   chronic. 


Certain  conditions  exist  which  present 
most  of  the  symptoms  of  cystitis,  but 
no  infection;  the  most  difficult  of  which 
to  diagnose  is  probably  urinary  hyper- 
acidity of  neuropathic  origin,  the  suc- 
cessful treatment  of  which  depends 
upon  the  successful  recognition  of  both 
its  urinary  features  and  its  general 
basis. 

Although   the   diagnosis   of  renal   in- 
fections can  be  made  with  absolute  cer- 
tainty only  by  ureteral  catheterization, 
a  probable  differentiation  between  renal 
and  vesical  infections  can  be  made  by  a 
careful  study  of  the  urine  alone.    Tuber- 
culous infections  of  the  urinary  tract 
frequently  occur  with  no  other  demon- 
strable   tuberculous    lesions    elsewhere 
in   the   body.     Probably   a   tuberculous 
gland  would  be  demonstrable  post-mor- 
tem in  most  of  these  cases.    The  colon 
bacillus    seems    to    be    the    commonest 
cause  of  pyelitis,  while  the  bacillus  pro- 
teus    vulgaris     and     members     of     the 
staphylococcic  group  are  also  found  less 
frequently.     And  finally  to  be  able  to 
thoroughly    understand    the    cases    of 
cystitis,     pyelitis,     and     pyelonephritis 
brought    to    our    notice,   to    make    the 
proper    diagnosis,    to    inaugurate    and 
carry  out  a  rational  line  of  treatment, 
and  to  give  a  correct  prognosis,  a  care- 
ful chemical  and  bacteriological  study  of 
the  urine  is  absolutely  essential.    T.  R. 
Brown   (Jolins  Hopkins  Hosp.  Reports, 
vol.  X,  Nos.  I  and  2,  1901). 
Prognosis. — The  prognosis  will  depend 
on  the  ability  of  the  surgeon  to  remove 
the  cause  and  on  the  duration  of  the 
disease.     Ordinary  acute  cystitis,  when 
uncomplicated,  is  not  attended  by  any 
great  danger.    Protracted  cases  of  acute 
vesical  catarrh  do  occur  and  may  run  a 
ver}'  chronic  course.    The  chronic  form 
is  to  be  regarded  as  troublesome  and  very 
intractable,  rather  than  dangerous  to  life. 
In  young  and  middle-aged  patients,  and 
in  those  of  good  constitution,  the  prog- 
nosis is  more  hopeful  and  the  treatment 
is  more  effectual  than  in  those  who  are 
advanced  in  years  or  enfeebled  by  disease. 
Treatment.— In  the  acute  form  the  pa- 


CYSTITIS.    TRKATMENT. 


369 


tient  should  be  ordered  to  bed  at  once. 
The  diet  should  be  light  and  unstimulat- 
ing:  milk,  broths,  eggs,  etc.    Stimulants 
are  to  be  avoided.    The  bowels  should  be 
regulated   by   the   administration   of   a 
saline.    In  point  of  fact,  all  such  cases 
are  better  for  the  use  of  some  drug  as 
the  citrate  of  magnesia,  epsom  salt,  Ilun- 
yadi  water,  etc.,  employed  to  the  point 
of  free  purgation.     Tyson  claims  that 
leeches  should  be  applied  to  the  per- 
ineum more  frequently  than  they  are. 
If  the  urine  is  acid,  it  should  be  rendered 
neutral  by  alkaline  drinks.    For  this  pur- 
pose H.  C.  Bloom  recommends  Vichy 
water  containing  much  soda.     In  most 
cases  the  urine  is  alkaline,  though  not  as 
frequently  in  the  acute  cases  as  in  those 
that  are  chronic.     The  best  remedy  for 
neutralizing  an  alkaline  urine  is  benzoic 
acid,  either  administered  in  solution  well 
diluted  with  water,  or  in  capsules  con- 
taining 5  grains  of  the  drug,  administer- 
ing every  three  hours  until  the  desired 
result  is  obtained.     Considerable  water 
should  be  taken  after  each  capsule.  'WTien 
there  is  much  ammoniacal  decomposi- 
tion, salol,  in  capsules  of  5  grains  each, 
given  every  two  hours  until  the  urine  is 
rendered  acid,  is  a  valuable  remedy.  Boric 
acid,  in  10-  or  20-gTain  doses  is  often 
efficacious.    A  weak  nitrate-of-silver  so- 
lution is  recommended  by  some  surgeons. 
When   the   urethro-vesical   tract  is  in 
such   a   condition   that  interference   can 
be  tolerated,  irrigations  with  a  nitrate- 
of-silver     solution,     beginning     with     a 
strength   of   1   to   16,000  and  increasing 
gradually,  are  effective.    Tliis  is  allowed 
to    flow    into   the   bladder   through   the 
anterior  urethra  by  the  force  of  gravity 
from   a   fountain-syringe,   the   height  of 
the    receptacle   being    sufficient    to    pro- 
duce enough   pressure  to   overcome  the 
resistance    of    tlie    cut-off    muscle.      So 
soon  as  the  patient  feels  the  tension  of 
the  fluid  in  the  bladder  the  flow  is  dis- 
continued and  the  patient  is  directed  to 
stand  and  empty  the  viscus.    These  irri- 


gations may  be  given  every  day,  or 
cvei-y  second  day,  as  the  patient's  symp- 
toms may  indicate.  Ramon  Guittras 
(N.  Y.  Alcd.  Jour.,  Mar.  19,  '98). 

In  cystitis  the  first  and  main  indica- 
tion for  treatment  must  be  to  render  the 
urine  antiseptic.  Urotropin  is  a  non- 
toxic and  non-irritating  derivative  of 
formic  aldehyde.  In  cases  of  cystitis 
and  of  phosphaturia  its  action  has  per- 
sonally been  almost  specific.  In  some 
cases  it  causes  a  slight  burning  s,ensa- 
tion  in  the  bladder  if  large  do'bes  are 
taken,  but  no  patient  to  whom  it  has 
been  personally  given  has  ever  com- 
plained of  this.  In  prescribing  urotropin 
the  reaction  of  the  urine  should  first  be 
discovered.  If  it  is  very  acid  a  little 
citrate  or  acetate  of  potassium,  or  if  it 
is  very  alkaline  a  little  dilute  mineral 
acid  should  be  given  in  addition  to  the 
drug.  T.  G.  Kelly  (Therap.,  Oct.  15, '98). 
The  value  of  urotropin  depends  more 
on  whether  (1)  the  cystitis,  as  a  primary 
bacterial  invasion,  develops  in  a  healthy 
urinary  tract,  in  which  condition  40  per 
cent,  were  personally  cured,  and  60  per 
cent,  improved,  or  (2)  whether  it  asso- 
ciates itself  with  a  pre-existing  disease 
of  the  tract,  as  stricture,  hypertrophied 
prostate,  tumor,  paresis,  nephrolithiasis, 
tuberculosis,  gonorrhoea,  etc.  In  these 
cases  urotropin  alone  is  useless,  yet  com- 
bined with  local  treatment,  while  there 
is  little  hope  of  cure,  there  may  be  much 
alleviation  of  the  symptoms  (in  49  cases, 
4  cured  and  30  improved).  If  (3)  the 
cystitis  is  secondary  to  an  infection  of 
the  urine,  urotropin,  like  santal  and 
salol,  is  utterly  useless  (10  cases,  10  fail- 
ures). B.  Goldberg  (Centralb.  f.  innere 
Med.,  July  14,  1900). 

In  cases  where  the  inflammation  is  too 
acute  to  tolerate  irrigations,  instillations 
of  nitrate  of  silver  are  of  great  value. 
They  should  be  given  with  the  Ultzmann 
or  the  Otis  syringe,  beginning  with  a 
strength  of  a  grain  to  the  ounce  and 
increasing  the  strength  to  ten  grains  if 
necessary.  From  5  to  20  drops  of  such  a 
solution  may  he  employed  at  one  time. 

Girl  of  19,  under  treatment  for  gonor- 
rhoea which  had  distinctly  involved  the 
24 


370 


CYSTITIS.    TREATMENT. 


uterine  mucous  membrane,  began  to  i 
complain  of  pain  during  micturition. 
On  examining  the  urine  gonococci  were 
detected  in  pure  culture.  Through  the 
cystoseope  the  vesical  mucosa  appeared 
very  vascular,  with  superficial  loss  of 
substance  at  certain  points.  The  cystitis 
was  cured  by  washing  out  the  bladder 
with  warm  boric  lotion  and  injection  of 
a  1-per-cent.  solution  of  nitrate  of  silver. 
Lindholm  (Cent.  f.  Gyn.,  No.  21,  '97). 

Pyoktanin  can  be  applied  to  the  most 
delicate  mucous  membrane,  not  only  in 
concentrated  solution,  but  in  powdered 
form  with  but  slight,  if  any,  irritation. 
It  retards  the  development  of  pus  even 
in  solutions  of  1  to  2000.    When  applied 
to  inflamed  mucous  membrane,  it  stains 
it  intensely  blue;  this  color  remains  for 
a  number  of  days.     It  is  active  as  an 
antiseptic  as  long  as  any  color  remains. 
In    treatment    of    inflammation    of    the 
bladder  and  urethra  injections  of  pyok- 
tanin solutions  into  the  bladder  produced 
the  happiest  results  in  four  cases.    R.  E. 
Graham  (N.  Y.  Med.  Jour.,  vol.  Ixvii,  p. 
889). 
Irrigations  and  injections  of  perman- 
ganate of  potash  in  V12-  to  Vrper-cent. 
Bolution  is  a  most  excellent  remedy.    In 
employing  vesical  irrigation  it  is  impor- 
tant to  observe  the  strictest  attention  to 
the  cleanliness  of  all  instruments  used. 
Large   injections   should   not   be   used. 
Better  an  ounce  or  so  at  a  time  fre- 
quently   repeated,    until    the    washings 
come  away  perfectly  clear.    The  temper- 
ature of  the  solution  should  be  about 
100°  to  105°  F.    When  there  are  local 
causes  for  reflex  irritability,  as  hemor- 
rhoids,   varicocele,    phimosis,    adherent 
prepuce,  or  a  narrow  meatus,  appropriate 
surgical  treatment  should  be  resorted  to. 
Urethral   causes   of   irritability   of   the 
bladder  or  of  partial  retention  of  the 
urine,  such  as  stricture  of  either  large  or 
small   calibre   should   be   promptly   at- 
tended to.    (White  and  Martin.) 

In  chronic  cystitis,  whatever  be  its 
origin,  the  treatment  of  the  inflamma- 
tion of  the  bladder  should  be  by  both 


local  and  internal  medication  until  it  is 
in  a  condition  that  will  permit  of  more 
radical  measures. 

Operative  interference  is  indicated 
when  the  symptoms  of  pain  and  fre- 
quency are  very  severe,  and  when  no 
improvement  has  resulted  from  general 
and  local  treatment;  distinctly,  there- 
fore, a  more  serious  group  of  cases. 
Curetting  the  bladder,  through  the  peri- 
neum in  the  male  and  through  the 
urethra  in  the  female,  followed  by  thor- 
ough drainage,  has  yielded  the  best  re-  ' 
suits.  The  perineal  route  is  preferred, 
because  it  is  easier,  because  it  gives 
readier  access  to  the  usual  situation  of 
tubercle  in  the  bladder,  and  because  the 
drainage  it  afltords  is  the  best.  The  only 
advantage  of  the  suprapubic  method  is 
that  of  allowing  one  to  see  the  seat  and 
extent  of  the  lesion.  Banzet  (Ann.  d. 
Mai.  d.  Org.  G6nito-Urin.,  June,  '97). 

In  women  the  lesions  of  cystitis  are, 
in  reality,  more  frequently  localized 
around  the  neck  of  the  uterus  and  of 
the  trigonum,  and  for  a  long  time  they 
are  rather  superficial.  It  is  only  in  e.t- 
trome  cases  that  the  condition  of  inter- 
stitial cystitis,  which  seems  to  be  be- 
yond therapeutic  resources,  becomes 
established.  In  such  cases  amelioration 
is  very  distinct  after  vesical  curetting. 
The  operation  is  very  simple  and  pre- 
ceded by  thorough  lavage  of  the  blad- 
der. For  this  a  solution  of  boric  acid 
is  used  to  which  1  per  cent,  of  a  solu- 
tion of  corrosive  sublimate  of  the 
strength  of  1  to  1000  without  alcohol 
is  added. 

According  to  Guyon,  this  intervention 
does  not  completely  cure  the  cystitis, 
but  it  renders  the  disease  more  amenable 
to  other  methods  of  topical  treatment 
which  before  could  not  be  tolerated. 

Treatment  may  be  summed  up  as  fol- 
lows; Treatment  of  the  uterus  and  its 
adnexa  and  general  treatment.  Local 
treatment  of  cystitis,  although  easy  in 
light  cases,  becomes  insufficient  in 
l)ronounced  cases.  Surgical  treatment 
becomes  necessary  in  cases  in  which  the 
I)ain  is  intense.  Cystotomy,  particularly 
colpocystolomy,  should  bo  reserved  for 
very  serious  cases.  Very  often  recov- 
ery or  a  step  toward  recovery,  by  means 


CYSTITIS.    TREATMENT. 


371 


of  local  topical  treatment,  may  be  ob- 
tained by  curetting  the  bladder  through 
the  urethra.  This  operation  is  simple 
and  easy;  it  does  not  require  any  com- 
plemental  operation,  and  it  gives  ex- 
cellent results.  M.  G.  Camero  (Gaz. 
Heb.  de  Mod.  et  de  Chir.,  Sept.,  '97). 

The  use  of  the  curette  advocated  in 
cases  of  non-tuberculous  chronic  cystitis 
that  will  not  yield  to  ordinary  treatment, 
or  even  the  radical  surgical  means,  such 
as  drainage  of  the  bladder  by  either  the 
perineal   or   suprapubic   routes.      N.   W. 
Soble   (BuiTalo  Med.  Jour.,  May,   1900). 
In  chronic  cystitis  in  the  female  subli- 
mate instillations   will   often  produce  a 
very  great  improvement  in  the  distress- 
ing symptoms  met  with  in  both  tubercu- 
lous   and    non-tuberculous    cystitis.      In 
some  cases  a  complete  cure  may  be  ob- 
tained when  the  instillations  fail  to  pro- 
duce the  desired  effect  by  curettement 
of  the  bladder  in  both  tuberculous  and 
non-tuberculous  cystitis;    in  gonorrhceal 
cystitis    instillations    of    sublimate    are 
particularly  efficacious;    under  favorable 
circumstances  a  radical  cure  of  tubercu- 
lous cystitis  may  be  obtained  by  curette- 
ment when  the  vesical  lesions  are  local- 
ized and  the  kidneys  free  from  the  dis- 
ease.    When    the  lesions   are   extensive, 
they     should     be     directly     treated     by 
suprapubic  cystotomy.     When  cystitis  is 
caused  by  a  prolapsus  of  the  genital  or- 
gans, and    when   hysteropexy,   combined 
with  anterior  and  posterior  colporrhaphy 
does  not  relieve  the  bladder  symptoms, 
curettement  of  the  bladder,  followed  by 
sublimate    instillations,    is    the    proper 
treatment.     C.  G.  Cumston   (N.  Y.  Med. 
Jour.,  Sept.  22,  1900). 
The  next  step  is  to  remove  the  cause 
of  the  trouble,  if  discoverable.     Strict- 
ures of  the  urethra  must  be  dilated,  for 
eign  bodies  must  be  removed,  retention 
of  the  urine  from  enlargement  of  the 
prostate  or  paralysis,  etc.,  must  be  treated 
by  the  regular  use  of  the  catheter  and 
then  by  such  operative  interference  as  is 
deemed    best   suited    to    tlic    individual 
case. 

A  soft  catheter  should  be  used  and  as 
often  as  the  viscus  will  allow  without 


adding  to  the  irritability  present,  twice  or 
three  times  in  the  twenty-four  hours  not 
being  too  frequent. 

A  large  percentage  of  female  patients 
suffering  with  subacute  vesical  symptoms 
— as  painful  micturition,  bearing-down 
sensation,  and  a  feeling  that  the  bladder 
is  not  emptied  after  micturition— can  be 
readily  relieved  by  dilatation  of  th« 
urethra.  The  greatest  amount  of  prac- 
tical good  that  has  been  obtained  in 
bladder  troubles  is  by  the  use  of  the 
cystoscope.  J.  M.  Baldy  (Phila.  Poly- 
clinic, No.  18,  p.  100,  '95). 

The  ordinary  bougie,  either  metallie 
or  soft,  can  be  rendered  sterile  by  wash- 
ing carefully  and  drying  with  a  towel  or 
gauze  rendered  sterile  by  boiling.  The 
use  of  antiseptic  solutions  is  unnecessary. 
As  soon  as  they  become  scratched  or 
injured,  metal  bougies  should  be  polished 
and  replated,  while  soft  ones  must  be 
thrown  away.  Metal  or  Jaques's  soft- 
rubber  catheters  can  be  rendered  posi- 
tively sterile  by  boiling  or  washing,  and 
soaking  in  strong  antiseptic  solutions 
that  do  not  injure  them.  It  is  impossible 
to  render  gum-elastic  or  varnished  cath- 
eters sterile  when,  for  any  reason,  they 
have  to  be  employed.  A  gum-elastic 
catheter  that  is  smooth  and  well  finished 
inside  may  be  rendered  reasonably  secure 
by  having  the  patient  hold  it  for  a  time 
under  a  tap  and  then  lay  it  aside  im- 
mersed in  a  boric  solution,  a  weak  per- 
chloride,  or  other  weak  antiseptic  solu- 
tion. When  the  urine  is  purulent  or  sep- 
tic, the  catheter  must  be  destroyed  if  it 
is  not  metal  or  soft  rubber.  ^Vhere  there 
is  not  much  pus  or  infection,  it  can  be 
washed,  immersed  in  antiseptic  solutions, 
and  steamed  internally.  Nicoll  (Annals 
of  Surg.,  June,  '99). 

The  best  internal  remedies, — i.e.,  those 
usually  praised — are  benzoic  acid,  about 
30  grains  a  day  in  divided  doses;  ben- 
zoate  of  sodium,  10  grains  four  times  a 
day;  salol,  in  a  similar  dosage;  and  uro- 
tropin,  7 '/,  grains  three  or  four  times 
a  day,  well  diluted  with  water. 

If  there  is  residual  urine  in  the  blad- 
der, it  is  only  a  question  of  time  as  to 


372 


CYSTITIS.    TREATJIENT. 


when  that  urine  will  decompose  and 
give  rise  to  cystitis.  Women  seldom 
completely  empty  the  bladder  while 
lying  perfectly  flat  on  the  back.  Hence, 
when,  on  account  of  illness,  they  are 
placed  on  the  back  sufficiently  long, 
cystitis  may  occur.  Cases  cited  in  which 
cystitis  supervened  after  an  inters'al  of 
ten  days,  and  in  another  as  soon  as  three 
days  after  operation.  In  appropriate 
eases,  the  recumbent  posture  should  be 
changed  to  the  sitting  posture  when  at 
all  possible.  To  correct  the  offensive 
odor,  salol  and  betol  are  useful.  A  dose 
of  5  grains,  three  times  daily,  of  betol, 
will,  as  a  rule,  completely  correct  the 
odor  in  twenty-four  to  thirty-six  hours. 
TV.  H.  Bennett  (Clinical  Jour.,  Mar.  27, 
'95). 

In  gonorrhoeal  cystitis,  rest  in  bed, 
avoidance  of  all  local  irritations,  admin- 
istration of  morphine,  codeine  rectal 
suppositories,  or  of  extract  of  hyoseya- 
mus,  use  of  local  warm  baths;  forbid- 
ding of  spices,  alcohol,  and  carbonated 
waters,  and  the  giving  of  laxatives. 
Priapism  can  be  avoided  by  the  bro- 
mides, with  camphor  or  cannabis  Indica. 
For  the  cystitis  itself,  salol,  in  three 
doses  of  15  grains  each,  sodium  salicy- 
late, or  sodium  benzoate  are  useful.  If 
the  digestion  is  excellent,  oil  of  santal, 
cubeb,  kava-kava,  balsam  of  copaiba, 
balsam  of  Peru,  and  oil  of  turpentine 
may  be  employed.  Of  importance  is  the 
use  of  infusions,  as  of  uva  ursi,  quite 
likely  on  account  of  their  diluting  the 
urine.  M.  Harovitz  (Centralb.  f.  d. 
Gesammte  Therapie,  H.  2,  S.  05,  '97). 

Bladder  lavage  with  salt-water,  and 
the  application  of  oil  containing  iodo- 
form and  guaiaeol,  is  a  method  sug- 
gested by  the  good  effects  which  arti- 
ficial serum  produces  in  tuberculosis  of 
the  peritoneum,  as  well  as  the  general- 
ized and  stimulating  action  which  it  ex- 
ercisca  upon  the  nutrition  of  the  tissues. 
The  phyHiological  solution  of  chloride  of 
sodium  was  left  in  the  bladder  in  con- 
siderable quantity,  directing  the  patient 
to  hold  it  as  long  as  posHible.  To  pro- 
duce a  tolerance  by  the  bladder,  olive-oil 
containing  5  per  cent,  of  guaiaeol  and 
from  1  to  2  per  cent,  of  iodoform  was 


injected.  The  iodoform  deposits  itself 
upon  the  mucous  membrane,  especially 
at  the  points  of  ulceration,  and  thus 
forms  a  kind  of  protective  film.  These 
applications  are  attended  with  the  irri- 
gations with  normal  salt  solution.  The 
pain,  bleeding,  and  other  well-known 
symptoms  of  this  disease  soon  disap- 
pear. A.  Montford  (La  Semaine  M6- 
dicale,  Dec.  10,  1902). 

The  patient  should  be  advised  to  drink 
freely  of  water  and  should  be  careful 
regarding  diet.  Locally  the  bladder 
should  be  washed  out  once  or  twice  a 
day  with  a  solution  of  permanganate  of 
potash  ^Aooo  to  ^/sooo ;  silver  nitrate  in  a 
similar  strength;  boric  acid,  10  grains  to 
the  ounce;  bichloride  of  mercury,  ^/looo 
to  Vmo  ■ 

In  cj'stitis  due  to  enlarged  prostate  the 
question  of  operation  has  to  be  consid- 
ered, and  includes  such  procedures  as 
castration  (White's  operation);  resection 
of  a  portion  of  the  vas  deferens;  enuclea- 
tion of  the  prostate;  incisions  of  the 
prostate  (Bottini's  method),  etc. 

Anodynes  are  indispensable  in  many 
cases  of  cystitis  to  relieve  the  frequent 
desire  to  urinate  and  the  extreme  pain 
the  patient  suffers.  They  are  best  given 
per  rectum  and  in  the  form  of  opium  or 
its  alkaloids.  Many  cases  demanding 
operation  for  the  relief  of  the  distressing 
symptoms  inevitably  associated  with 
chronic  inflammation  of  the  bladder  are 
only  relieved  by  such  measures  as  a 
suprapubic  cystotomy  or  a  perineal  sec- 
tion. 

[The  severe  pain  attending  the  pas- 
sage of  urine  is  often  relieved  by  the  use 
of  5-grain  doses  of  chloride  of  ammo- 
nium every  three  hours,  especially  if  lit- 
mus-paper show  the  urine  to  be  acid. 
Ed.] 

Lewis  H.  Adler,  Jr., 

Philadelphia. 


DEAF-MUTISM.    DEFINITION.    CLASSIFICATION. 


373 


D 


DACRYOADENITIS. 

Appaeatus. 


See  Lacrtiial 


DACRYOCYSTITIS.  See  Lacrymal 
Appahatos. 

DANDRUFF.     See  Seborrhcea. 

DEAF-MUTISM. 

Definition.  —  Deaf  -  mutism,  strictly 
speaking,  signifies  the  abnormality  which 
is  characterized  by  the  co-existence  of 
deafness  and  dumbness.  Various  cir- 
cumstances, which  will  be  treated  of  in 
the  following  pages,  necessitate,  how- 
ever, a  more  limited  definition.  Deaf- 
mutism  may,  therefore,  be  defined  as  a 
pathological  condition  dependent  upon 
an  anomaly  of  the  auditory  organs,  either 
congenital  or  acquired  in  early  child- 
hood, causing  so  considerable  a  diminu- 
tion of  the  power  of  hearing  as  to  pre- 
vent the  acquisition  of  speech,  or — 
should  speech  have  been  acquired  before 
the  occurrence  of  the  loss  of  hearing — 
as  to  prevent  its  preservation  by  the  aid 
of  hearing  alone.  Persons  exhibiting 
this  pathological  condition  are  described 
as  deaf-mutes,  even  when  speech  has 
been  acquired  by  a  special  system  of  in- 
struction. 

Theoretically,  deaf-mutism  is  an  ill- 
defined  condition,  which  cannot  be  dis- 
tinctly separated  from  other  conditions 
related  to  it.  This  is  a  natural  conse- 
quence of  its  being  a  pathological  term 
founded,  not  only  upon  a  symptom,  deaf- 
ness, but  also  \ipon  the  intensity  of  that 
symptom  and  the  period  of  its  occur- 
rence. There  is,  also,  an  apparent  con- 
tradiction in  the  fact  that  deaf-mutes  in- 
clude, not  only  those  who  cannot,  but, 
also,  those  who  can,  hear  or  speak.  Prac- 
tically, however,  there  is  seldom  any  dif- 


ficulty in  determining  whether  a  person 
is  or  is  not  a  deaf-mute,  just  as  it  is,  also, 
as  a  rule,  easy  to  recognize  deaf-mutism, 
when  the  subject  in  question  has  passed 
the  first  years  of  infancy.  The  reason  is 
that  the  acquisition  and  preservation  of 
speech  in  childhood  is  so  dependent  upon 
hearing  that,  as  soon  as  the  latter  sinks 
below  a  certain  degree,  the  former  can- 
not be  •  developed,  or  is  lost,  and  this 
secondary  dumbness  does  not  easily  es- 
cape observation.  Occasionallj',  it  may 
be  difficult  to  decide  whether  a  child 
should  be  described  as  a  deaf-mute  or  as 
merely  deficient  in  hearing  and  speak- 
ing. Such  cases  must  be  decided  by 
purely  practical  considerations,  and  it 
may  not  be  out  of  the  way  to  observe 
that  in  Denmark — one  of  the  few  coun- 
tries where  the  education  of  deaf-mutes 
is  compulsory — all  children  are  consid- 
ered deaf-mutes  who  cannot,  owing  to 
their  deficient  hearing,  take  part  in  the 
instruction  given  to  normal  children. 

Classification,  —  Deaf-mutism  can  be 
classified  (1)  either  according  to  the  de- 
gree of  its  symptoms,  or  (2)  according  to 
its  etiology.  In  the  first  case  a  distinc- 
tion must  be  made  according  as  the  deaf- 
ness or  dumbness  is  absolute  or  not.  True 
deaf-muiism  may  be  described  as  being 
the  state  in  which  the  hearing  is  posi- 
tively nil,  and  in  which  there  is  no  power 
of  speech,  unless  it  be  acquired  by  a 
special  method  of  instruction.  Persons 
with  this  form  of  deafness  may  be  desig- 
nated as  true  deaf-mutes.  Those  who 
have  some  slight  power  of  hearing  or 
some  power  of  speech  (either  because  the 
hearing  is  not  totally  absent  or  because 
the  deafness  occurred  after  speech  had 
been  acquired)  may  be  described  as  swnt- 
muics. 

Etiologically,   deaf-mutism   has   been 


374 


DEAF-MUTISM.    CLASSIFICATION.    DISTRIBUTION. 


further  divided  into  endemic  deaf-mutism 
{i.e.,  that  which  attaches  to  certain  dis- 
tricts and  their  natural  conditions)  and 
sporadic  deaf-mutism  (which  is  the  re- 
sult of  certain  accidental  causes). 

The  most  general  classification  of  deaf- 
mutism  is  that  which  discriminates  be- 


the  cases  of  deaf-mutism  are  caused  by 
acquired  deafness.  The  relative  propor- 
tion must,  however,  vary  very  much  in 
different  places  and  at  different  periods, 
epidemics  of  certain  infectious  diseases, 
for  instance,  increasing  the  absolute 
number    of    deaf-mutes    with    acquired 


Distribution 
Countrv. 

Europe : 

Switzerland    

Austria    

Baden    

Sweden    

Alsace  and  Lorraine. . . . 

Wiirtemberg    

Hungary  

Norway  ■. 

Prussia    

Finland  

Bavaria  

Ireland    

Portugal   

Greece   

Denmark    

France  

Saxony    

Scotland    

Italy    

England- Wales    

Spain  

Belgium    

Holland     

America  : 

Canada    

United  States 

Africa : 

Cape   Colony 

Asia  : 

British  India 

Australia  : 

English  Colonies 


OF   DE.\F-MnTES   IN   VARIOUS   COUNTRIES. 


Year. 
1870 

1890 
I87I 
1895 
1871 
1861 
1890 
1891 
1880 
1880 
1871 
1880 
1878 
1879 
1890 
1876 
1890 
1881 
1881 
1891 
1877 
1875 
1889 

1891 
1890 

1890 

1891 

1891 


luhabiUut: 

245 

123 

122 

116 

111 

111 

109 

106 

102 

102 

90 

77 

75 

65 

65 

58 

57 

57 

54 

50 

46 

43 

43 

100 
66 

63 

69 

37 


6,544 

29,217 

1,784 

5,307 

1,724 

1,910 

19,024 

2,139 

27,794 

2,098 

4,381 

3,993 

3,109 

1,085 

1,411 

11,460 

1,994 

2,142 

15,300 

14,112 

4,625 

1,208 

1,977 

4,819 
41,283 

802 

190,843 

1,412 


Proiiortioii  between 

Mule  iiiul  FouiHle 

Detif- mutes. 


100:74 
100:89 
100:90 
100:76 
100:87 
100:84 
100:81 
100:83 
100:77 
100:94 
100:87 
100:73 

100:89 
100:87 
100:85 
100:86 
100:76 
100:83 
100:05 
100:89 
100:81 

100:80 
100:81 

100:78 

100:64 


tween  the  deaf-mutism  resulting  from 
congenital  pathological  changes  of  the  or- 
gans of  hearing  and  that  resulting  from 
Buch  changes  which  are  acquired  after 
birth. 

We  have  reason  to  surmise,  according 
to  modern  statistics,  that  at  least  half 


deafness.  Future  investigations  will,  per- 
haps, prove  that  acquired  deafness  has  a 
still  greater  preponderance  in  tlio  causa- 
tion of  deaf-mutism  than  we  are  at  pres- 
ent authorized  in  believing. 

Distribution. — We  are  only  in  posses- 
sion of  information  as  to  the  distribution 


DEAF-MUTISM.     SY^ilPTOMS  AND  SEQUELS. 


375 


of  deaf-mutism  in  Europe,  the  United 
States  of  America,  and  some  European 
colonies.  Not  even  all  European  coun- 
tries have  undertaken  an  enumeration  of 
their  deaf-mute  population;  Kussia,  the 
largest  of  them,  having,  for  instance,  no 
deaf-mute  statistics.  The  table  on  page 
439,  which  includes  the  most  recent 
enumeration  of  deaf-mutes,  gives  their 
numbers  in  different  countries,  also  the 
proportion  of  males  and  females. 

It  will  be  seen  from  this  table  that 
deaf-mutism  is  very  variousl}'  distributed 
in  the  countries  from  which  we  possess 
statistics.  The  causes  of  the  remark- 
ably unequal  geographical  distribution  of 
deaf-mutism,  which  will  be  seen  from 
the  table,  are  probably  numerous  and 
various.  To  begin  with,  we  are  involun- 
tarily struck  by  the  fact  that  the  Euro- 
pean countries,  with  large  deaf-mute 
population,  are  the  most  mountainous, 
which  is  in  perfect  accord  with  the  fact 
that  deaf-mutism  is  more  frequent  in 
mountainous  that  in  lowland  districts. 
I  shall  later  on  have  occasion  to  point 
out  that  this  is  not,  in  all  probability,  the 
result  of  great  altitudes  and  peculiar  geo- 
logical formations,  but  of  the  unfavor- 
able social  and  hygienic  conditions  com- 
mon to  mountainous  countries  (consan- 
guinity, poverty,  unhealthy  dwellings, 
etc.),  the  importance  of  which  as  causes 
of  deaf-mutism  will  be  discussed  after- 
ward. Further,  wide-spread  and  malig- 
nant epidemics  of  cerebrospinal  menin- 
gitis, an  important  cause  of  deaf-mutism, 
explain  the  frequency  of  this  condition  in 
the  lowland  countries  of  Central  Europe. 

We  must,  also,  observe  that  the  coun- 
tries in  the  west  and  south  of  Europe  are 
the  most  fertile  and  productive,  while 
those  in  the  north  and  centre  are  less 
favorably  endowed  by  nature.  That  this 
circumstance  is  a  factor  in  the  distribu- 
tion of  deaf-mutism  has  been  proved  by 


investigations  made  in  different  districts 
in  Denmark,  and  especially  in  Saxony. 
Finally,  the  northern  and  central  coun- 
tries are,  on  the  whole,  the  most  thinly 
populated  in  Europe,  doubtless  the  re- 
sult of  the  barrenness  of  the  soil. 

Sex. — The  table  on  page  439  shows  a 
greater  frequency  of  deaf-mutism  among 
males  than  females,  the  difEerence  in  sev- 
eral countries  being  considerable.  The 
number  of  female  deaf-mutes  per  100 
male  deaf-mutes  varies,  according  to  the 
table,  from  94  in  Bavaria  to  65  in  Spain, 
the  average  rate  in  Europe  and  the 
United  States  of  America  being  82  fe- 
males per  100  males.  The  numerical 
superiority  of  male  deaf-mutes  is  the 
more  remarkable  since  females  are  more 
numerous  than  males  in  nearly  all  the 
European  countries,  Italy  being  the  only 
country  of  those  mentioned  in  the  table 
which  exhibits  a  slight  inferiority  as  re- 
gards the  female  population.  This  nu- 
merical superiority  of  the  male  deaf- 
mutes  must  undoubtedly  be  considered 
principally  as  an  expression  of  the 
greater  liability  the  male  organ  of  hear- 
ing has  to  be  morbidly  affected. 

Symptoms  and  Sequelse. — Of  the  s}Tnp- 
toms,  the  principal  are,  of  course,  deaf- 
ness and  dumbness;  but  other  symptoms 
closely  connected  with  the  ear  disease 
causing  deafness  are  often  met  with  in 
cases  of  deaf-mutism. 

Deafness. — The  term  "deafness"  is 
not  only  used  to  express  the  absolute  ab- 
sence of  hearing, — total  deafness, — but 
also  to  express  a  condition  in  which  some 
traces  of  hearing  remain,  but  in  which 
the  human  voice  is  not  audible  in  the 
usual  way:  a  condition  to  be  described  as 
partial  deafness.  From  a  theoretical 
point  of  view,  it  seems  an  easy  matter  to 
make  a  sharp  distinction  between  the 
condition  in  which  the  axiditory  nerve  is 
entirelv   out   of   function   and   that   in 


376 


DEAF-MUTISM.     SYMPTOMS  AND  SEQUEL.E. 


"whicli  it  still  acts,  though  deticiently. 
As  a  matter  of  fact,  however,  it  has  been 
proved  that  it  is  sometimes  difficult  to 
decide,  in  particular  cases,  whether  there 
are  any  remains  of  hearing  or  not;  and, 
further,  the  results  of  these  two  condi- 
tions (if  acquired  in  early  infancj'  or 
congenital)  are  the  same,  viz.:  deaf- 
mutism.  In  other  words,  both  subjects 
with  total  deafness  and  those  with  par- 
tial deafness  may  be  met  with  among 
deaf-mutes. 

It  is  not  always  an  easy  matter  to  test 
and  decide  the  amount  of  hearing  pos- 
sessed by  a  child,  especially  an  infant. 
As  a  rule,  only  ordinary  loud  sources  of 
sound  can  be  employed  to  discover 
whether  the  child  in  question  reacts  in 
any  way  to  the  sound  produced;  for 
instance,  by  turning  or  blinking  its  eyes. 
Generally,  a  loud  whistle,  a  bell,  clap- 
ping the  hands,  or  such  like  devices  are 
made  use  of.  Such  a  rough  mode  of  ex- 
amination can,  however,  only  decide 
whether  the  power  of  hearing  exists  or 
not  in  individual  cases,  and  even  this  is 
often  difficult  when  the  patient  is  an 
infant,  and  it  is  also  no  easy  matter  to 
determine  whether  the  power  of  hearing 
is  equal  on  both  sides.  With  older  chil- 
dren it  is  easier  to  discover  whether  the 
power  of  hearing  exists,  and,  if  so,  in 
what  degree.  In  the  latter  case  less  pow- 
erful sources  of  sound  may  be  employed. 
Of  these  the  principal  is  the  tuning-fork, 
the  vibrations  of  which  are  used  in  meas- 
uring the  conduction  of  sound  through 
the  middle  ear,  by  placing  it  outside 
the  ear;  and  also  in  measuring  the  so- 
called  bone,  or  cranio-tympanic,  con- 
duction, by  placing  it  on  the  mastoid 
process  or  on  the  teeth.  The  human 
voice  is  also  an  important  means  of  in- 
vestigation. The  best  means  of  employ- 
ing it  is  by  pronouncing  certain  vowels 
loudly  and  distinctly  close  to  the  deaf- 


mute's  ear,  without  his  being  able  to  see 
the  movement  of  the  lips,  the  patient 
being  asked  to  repeat  the  vowels  pro- 
nounced. To  prevent  the  possibility  of 
guessing  the  vowels  should  be  repeated 
several  times.  If  the  deaf-mute  under- 
stands the  vowels  easily,  consonants  and 
even  words  and  short  sentences  may  be 
tried.  In  most  cases  this  method  can 
only  be  made  use  of  when  the  deaf-mute 
in  question  has  learned  to  articulate.  A 
greater  power  of  hearing  is  seldom  met 
with,  unless  sound-increasing  apparatus 
are  employed.  The  hearing  of  deaf- 
mutes  with  considerable  remains  of  hear- 
ing can  also  be  tested  with  a  loud-ticking  . 
watch  placed  outside  the  ear  or  pressed 
against  the  outer  ear.  It  is,  however, 
very  unusual  for  deaf-mutes  to  be  able 
to  distinguish  the  high  notes  represented 
by  the  ticking  of  a  watch.  In  employing 
all  these  methods,  it  must  be  remem- 
bered that  the  hearing  of  deaf-mutes  dif- 
fers greatly  at  different  times  in  some 
cases,  according  to  varying  conditions  in 
the  ear,  of  which  we  have  no  immediate 
knowledge. 

The  reports  of  various  investigators, 
as  to  the  relative  number  of  deaf-mutes 
with  total  deafness,  differ  considerably, 
for,  while  some  have  found  that  only 
about  one-fourth  of  the  deaf-mutes  ex- 
amined were  totally  deaf,  others  have 
found  a  much  larger  proportion,  the 
principal  cause  of  this  discrepancy  being 
probably  the  fact  that  there  is  generally 
a  distinct  relationship  between  the  deaf- 
ness and  its  cause.  This  relationship  is 
most  distinctly  seen  by  comparing  the 
power  of  hearing  of  congenital  deaf- 
mutes  with  that  of  deaf-mutes  with  ac- 
quired deafness.  All  investigators,  with 
a  few  exceptions,  have,  namely,  found  a 
much  greater  number  of  cases  of  total 
deafness    among    deaf-mutes    with    ac- 


DEAF-MUTISM.    SYMPTOMS  AND  SEQUELAE. 


377 


quired  deafness  than  among  deaf-mutes 
with  congenital  deafness. 

The  reason  why  so  many  more  cases  of 
total  deafness  are  met  with  among  deaf- 
mutes  with  acquired  deafness  than 
among  those  with  congenital  deafness  is 
owed  to  the  fact  that  post-natal  proc- 
esses in  the  ear  causing  deafness  are 
much  more  destructive  than  the  same 
processes  occurring  during  foetal  life:  a 
circumstance  which  has  been  previously 
pointed  out.  Most  authors  have  also 
found  that  congenital  deaf-mutes  are 
more  frequently  in  possession  of  a  con- 
siderable degree  of  hearing  (hearing  of 
vowels  or  even  of  words)  than  deaf-mutes 
with  acquired  deafness. 

It  may  be  mentioned,  finally,  that 
Bezold  examined  the  hearing  power  of 
deaf-mutes  by  means  of  a  graduated 
series  of  tuning-forks  and  found  that 
frequently  "islands"  of  perception  of 
notes  alternated  with  total  defects  of 
hearing.  These  defects  appeared  most 
frequently  in  the  lower  end  of  the  scale 
— a  fact  which  has  been  corroborated  by 
Uchermann. 

Mutism. — Mutism  was  in  early  times 
believed  to  be  the  primary  and  essential 
symptom  of  deaf-mutism,  but  it  is  known 
now  to  be  a  secondary  phenomena  which 
is  the  consequence  of  the  deafness.  That 
this  is  the  case  is  also  evident,  from  the 
fact  that  the  degree  of  mutism  is,  as  a 
rule,  in  exact  relation  to  the  degree  of 
deafness,  and  also  to  the  period  at  which 
the  deafness  makes  its  appearance.  Thus 
congenital  deafness,  or  deafness  acquired 
in  early  infancy,  is  always  accompanied 
by  complete  mutism  (excepting  in  cases 
in  which  the  mutism  is  removed  by 
special  methods  of  education),  while  in 
cases  of  acquired  deafness,  in  which  the 
deafness  is  either  not  total  or  arises  after 
the  child  has  learned  to  speak,  a  certain 
degree  of  speech  is  respectively  acquired 


or  retained.  The  explanation  is  simple, 
speech  being,  under  normal  circum- 
stances, acquired  through  the  ear,  the 
child  imitating  the  words  which  it  hears 
spoken  by  those  about  it.  It  may,  how- 
ever, be  mentioned  that  even  children 
totally  devoid  of  hearing  produce 
sounds  which  sometimes  resemble  words, 
such  as  "ma-ma,"  'T)a-ba,"  etc.,  and 
sometimes  also  imitate  animals,  often 
thus  causing  their  friends  to  suppose  that 
they  are  capable  of  hearing.  This  may 
be  because  the  above-mentioned  sounds 
and  the  voices  of  certain  animals  are 
produced  by  very  simple  movements  of 
the  vocal  organs  which  can  be  imitated 
by  spontaneous  observation.  Finally,  it 
is  possible  that  the  vibrations  caused  by 
such  loud  soimds  as  the  barking  of  a 
dog,  bellowing  of  a  cow,  etc.,  may  be 
perceived  by  the  aid  of  touch,  which 
sense  is  often  highly  developed  in  deaf 
children,  and  consequently  guides  them 
in  imitating  the  sounds. 

The  question  as  to  the  degree  of  deaf- 
ness which  must  exist,  or,  in  acquired 
cases,  the  age  at  which  the  deafness  must 
appear  in  order  to  cause  mutism  result- 
ing in  deaf-mutism,  cannot  be  answered 
decidedly.  To  begin  with,  the  applica- 
tion of  the  term  "deaf-mutism"  is  en- 
tirely arbitrary  in  cases  in  which  there  is 
some  power  of  hearing  or  of  speech,  and 
the  distinction  between  a  deaf-mute  child 
and  a  child  with  deficient  power  of  hear- 
ing must  in  some  cases  depend  entirely 
upon  practical  considerations,  of  which 
the  method  of  instruction  which  is  requi- 
site for  the  child's  education  is,  as  a 
rule,  decisive.  Thus,  for  instance,  a  child 
of  well-to-do  parents,  who  is  able  to  hear 
tunes  and  to  a  certain  extent  reproduce 
them,  will  scarcely  be  considered  deaf 
and  dumb  and  sent  to  an  asylum,  while  a 
child  with  the  same  degree  of  hearing, 
but  of  poor  parents,  will  be  treated  as  a 


378 


DEAF-iaTISM.     SYMPTOMS  AND  SEQUEL.E. 


deaf-mute,  because  the  parents  are  un- 
able to  give  it  the  special  education  which 
it  requires.  The  non-development  or 
deficient  development  of  the  power  of 
speech  in  cases  of  congenital  partial  deaf- 
ness, and  its  complete  or  partial  loss  in 
cases  of  acquired  deafness,'  are  also  often 
dependent  upon  the  assiduity  with  which 
a  child's  friends  attend  to  its  develop- 
ment or  preservation.  Some  children, 
too,  seem  to  have  a  greater  aptitude  for 
developing  or  retaining  the  power  of 
speech  than  others,  and  this  seems  to  be 
not  only  dependent  upon  their  intellect- 
ual faculties,  but  also  upon  other  un- 
known conditions.  Thus,  a  child  with 
comparatively  very  slight  power  of  hear- 
ing, or  with  deafness  acquired  soon  after 
birth,  may  exhibit  a  comparatively  con- 
siderable power  of  speech,  while  another 
child  with  greater  powers  of  hearing  and 
later  acquired  deafness  may  be  entirely 
without  it. 

Future  investigations  will  in  all  proba- 
bility decide  how  far  total  acquired  deaf- 
ness results  in  total  njutism.  Hartmann 
states  that  deafness  acquired  before  the 
age  of  seven  causes  secondary  mutism, 
and  this  opinion  is,  no  doubt,  correct. 
On  the  other  hand,  there  are  reports  from 
various  places  to  the  effect  that  deaf- 
mutism  may  appear  at  the  age  of  14  or  15 
or  even  later.  In  these  cases,  however, 
it  is  probable  that  the  term  deaf-mutism 
is  incorrect,  though,  of  course,  such  acci- 
dental circumstances  as  feeble-minded- 
ness,  blindness,  etc.,  may  necessitate  the 
registration  of  persons  who  have  lost  the 
power  of  hearing  so  late  in  life  as  deaf- 
mutes,  because  they  are  unable  to  read 
from  the  lips,  or  unable  to  pronounce  so 
distinctly  as  to  be  understood. 

As  mentioned  above,  mutism  in  deaf- 
mutes  may  be  either  total — i.e.,  the  power 
of  speech  may  be  entirely  wanting — or  it 
may  be  partial,  in  which  latter  case  the 


power  of  speech  is  developed,  or,  in  ac- 
quired deaf-mutism,  it  is  retained  to  a 
certain  extent.  This  power  of  speech  is 
frequently  considerable;  so  that  such 
persons  cannot,  properly  speaking,  be 
termed  mutes.  There  are,  however,  cer- 
tain peculiarities  which  always  attach 
themselves  to  the  speech  even  of  persons 
who  are  only  partially  deaf  from  their 
birth,  or  who  have  become  deaf  during 
childhood.  These  peculiarities,  which 
are  still  more  pronounced  in  true  deaf- 
mutes,  consist  in  the  absence  of  accentua- 
tion of  syllables  and  of  words,  the  result 
being  that  speech  becomes  monotonous. 
Besides  this,  the  speech  of  such  persons 
is  generally  dull-sounding  and  feeble, 
and  the  control  of  respiration  is  also  de- 
ficient. The  stock  of  words  is  also  some- 
times limited,  though  this  peculiarity  is, 
under  ordinary  circumstances,  not  very 
noticeable,  excepting  in  cases  where  the 
power  of  hearing  is  very  slight,  or  where 
the  deafness  appears  comparatively  early. 
These  physical  deficiencies  in  the  speech 
of  deaf-mutes  are  easily  accounted  for, 
because  the  power  of  hearing  is  not  only 
important  in  the  development  of  speech 
by  enabling  a  child  to  imitate  the  speech 
of  others,  but  it  also  enables  it  to  regulate 
the  modulation,  sound,  and  force  of  its 
voice  by  the  aid  of  the  vibrations  which 
reach  the  labyrinth  through  the  bones  of 
the  cranium. 

The  power  of  hearing  plays  so  great  a 
part  in  the  above-mentioned  physical 
qualities  of  speech  that  its  loss  cannot 
be  completely  compensated  for  by  any 
other  sense.  It  is,  however,  possible,  by 
aid  of  sight  and  touch,  to  teach  a  great 
number  of  deaf-mutes  to  speak  well 
enough  to  be  able  to  use  speech  as  a 
means  of  commimication.  Persons  who 
have  been  totally  deaf  from  birth  can 
also  be  taught,  by  a  special  method  of 
instruction,  to  speak  so  that  they  can  be 


DEAF-MUTISM.    SYMPTOMS  AND  SEQUEL.^. 


379 


understood,  though  with  the  peculiarities 
above  mentioned.  Owing  to  these  pecul- 
iarities, such  speech  has  received  the 
name  of  "articulation."  It  is  not  always 
an  easy  matter  for  the  deaf-mute  to  re- 
tain the  power  of  speech  which  he  has 
gained  with  so  much  difficulty,  when  he 
enters  the  world  and  comes  in  contact 
with  persons  who  cannot,  or  can  only 
partially,  understand  him.  In  such  cases 
the  deaf-mute  generally  abandons  the 
use  of  speech  as  a  means  of  communica- 
tion, especially  as  lip-reading  requires 
great  attention  and  well-developed  sight. 
Disturbances  of  the  Equilibrium. 
— It  has  been  mentioned  that  acquired 
deafness  is  often  accompanied  by  disturb- 
ances of  the  equilibrium,  both  at  its  first 
appearance  and  immediately  afterward, 
and  that  this  complication  is  most  fre- 
quent in  cases  where  the  deafness  has 
been  caused  by  cerebrospinal  meningitis. 
Mention  is  also  made  in  literature  of 
some  few  cases  of  congenital  deafness 
accompanied  by  disturbances  of  the  equi- 
librium, consisting  in  uncertain  and  stag- 
gering gait,  both  during  the  first  years 
of  childhood  and  later  on  in  life.  James 
was  the  first  to  draw  attention  to  "im- 
munity from  dizziness,"  under  circum- 
stances which  otherwise  produce  dizzi- 
ness and  consequent  disturbance  of  the 
equilibrium,  as  characteristic  of  deaf- 
mutes.  He  examined  altogether  519 
deaf-mutes  and  found  that  18G — i.e.,  36 
per  cent. — did  not  feel  the  least  dizziness 
when  spun  round  rapidly,  no  matter  in 
what  position  their  heads  were  placed. 
James  was  also  informed  by  many  of 
these  deaf-mutes  that  they  Experienced 
a  remarkable  feeling  of  helplessness  and 
want  of  sense  of  locality  when  under 
water,  several  of  them  also  stating  that 
these  sensations  were  unkno\\'n  to  them 
before  the  loss  of  hearing.  Kreidl  en- 
deavored to  discover  in  a  more  rational 


manner,  and  by  the  aid  of  a  specially- 
constructed  apparatus,  an  objective  proof 
of  the  above-mentioned  phenomena  in 
deaf-mutes,  and  also  to  decide  their 
nature  and  strength.  Pollak  endeavored 
to  produce  dizziness  in  a  number  of 
deaf-mutes  by  conducting  a  galvanic 
current  through  their  heads.  Several 
exliibited  signs  of  dizziness,  accom- 
panied by  movements  of  the  head  and 
eyes,  also  exhibited  by  normal  subjects 
under  like  circumstances,  while  29.3 
per  cent,  were  not  affected  in  any  way; 
in  these,  then,  it  was  to  be  supposed  that 
the  semicircular  canals  were  entirely  de- 
stroyed, and  Pollak  points  out  the  resem- 
blance between  the  figures  thus  obtained 
and  the  percentage  of  cases  of  entire  ab- 
sence or  destruction  of  the  semicircular 
canals  found  by  post-mortem  examina- 
tion of  deaf-mutes. 

Although  deaf-mutism  brings  with  it 
a  long  train  of  indirect  consequences, 
which  are  of  great  importance  as  affect- 
ing the  daily  life  of  the  deaf-mute,  its 
more  direct  results  are  but  few,  and  even 
these  are  the  subject  of  dispute. 

Deficient  Development  of  the 
Mental  Faculties. — There  can  be  no 
doubt  that  the  want  of  such  an  important 
sense  as  hearing  must  at  least  result  in 
a  slow  development  of  the  mental  facul- 
ties, as  the  psychological  function  of  the 
brain  develops  not  only  in  proportion 
to  its  receptivity  to  impressions  from 
without,  which  are  so  necessary  for 
mental  growth  {"nihil  est  in  inteUedu 
quod  non  antea  fuerit  in  sensibus"),  and 
to  the  quality  of  these  impressions,  but 
also  in  proportion  to  their  quantity, 
which  must  of  necessity  be  diminished 
when  one  of  the  routes  by  which  they 
reach  the  brain  is  closed  or  partly  closed. 
This  does  not,  of  course,  prevent  a  deaf- 
mute  from  attaining  the  same  degree  of 
intellectual    development   as   a    normal 


3S0 


DEAF-MUTISM.     SYMPTOMS  AND  SEQUELS. 


person  with  the  same  amount  of  intelli- 
gence, if  his  physical  deficiency  is  com- 
pensated for  by  energy,  industry,  etc. 
There  is,  however,  no  doubt  that  purely 
practical  considerations — for  instance, 
the  necessarily-limited  choice  of  profes- 
sions— often  hinder  such  a  complete  in- 
demnification for  the  loss  of  so  impor- 
tant a  sense  as  hearing.  The  deaf-mute 
is  thus  deprived  of  one  of  the  most  im- 
portant incentives  to  energy, — namely, 
ambition;  and  it  is,  doubtless,  in  these 
external  hindrances,  that  the  reasons  are 
to  be  sought  why  no  deaf-mute  has  as 
yet  written  his  name  on  the  pages  of 
history.  Further,  the  morbid  processes 
causing  deaf-mutism  often  have  their 
seat  in  the  brain,  as  has  been  already 
pointed  o\it,  and  these  processes  often 
leave  other  traces  behind  them.  Hart- 
mann  found  also  that  one-half  of  the 
pupils  examined  by  him  in  deaf-and- 
dumb  asylums,  whose  deafness  was  due 
to  brain  disease,  were  but  moderately  or 
indifferently  endowed  with  intelligence, 
and  it  was  altogether  doubtful  whether 
many  of  these  subjects  were  capable  of 
instruction.  There  are  also  statistical 
proofs  from  other  countries  that  deaf- 
mutism  is  often  accompanied  by  want  of 
mental  power.  It  is  not,  however,  cor- 
rect to  infer  that  deaf-rautism  can  result 
in  idiocy  from  the  circumstance  that 
deaf-mutes  are  often  idiots.  Idiocy, 
when  it  appears  simultaneously  with 
deaf-mutism,  is  the  result  of  a  congenital 
brain  disease,  or  one  acquired  in  infancy, 
and  is  of  superior  or  co-ordinate  impor- 
tance to  the  deaf-mutism  itself;  persons 
exhibiting  both  these  abnormalities 
must,  doubtless,  not  be  considered  as  idi- 
otic deaf-mutes,  but  as  deaf-and-dumb 
idiots.  IT.  Schmaltz  and  Lemcke  have 
made  some  measurements  of  the  heads 
of  deaf-mutes  in  order  to  elucidate  the 
question  as  to  the  intelligence  possessed 


by  deaf-mutes.  Both  these  investigators 
found  that  the  heads  of  deaf-mute  chil- 
dren were,  as  a  rule,  smaller  than  the 
heads  of  normal  children,  especially  in 
the  younger  age-periods.  The  reason  is, 
doubtless,  that  the  mental  faculties  of 
deaf-mute  children  are  less  developed 
than  those  of  other  children. 

Abnoemalities  of  the  Ear  Found 
BY  Objective  Examination.  —  While 
the  section  of  this  paper  on  morbid  anat- 
omy will  be  mainly  devoted  to  the  path- 
ological changes  of  the  deeper  parts  of 
the  ear,  it  is  my  purpose,  under  this  head- 
ing, to  deal  with  the  abnormalities  found 
in  those  parts  of  the  ear  which  are  ac- 
cessible to  objective  examination.  It 
would  naturally  be  supposed  that  as  deaf- 
mutism  is  often  caused  by  anomalies  of 
the  ear,  deaf-mutes  would  often  exhibit 
congenital  abnormalities  of  the  external 
ear.  This  is,  however,  not  the  case,  as 
congenital  malformations  of  the  external 
ear  are  but  seldom  met  with.  A  close 
investigation  of  the  cases  of  malforma- 
tion of  the  external  ear  reported  in  lit- 
erature proves  also  that  these  abnormali- 
ties are  but  very  rarely  accompanied  by 
such  a  diminution  of  the  powers  of  hear- 
ing as  to  result  in  deaf-mutism,  which 
circumstance  has  been  laid  much  stress 
upon  by  Toynbee.  Abnormalities  of  the 
external  meatus  have  been  often  met 
with.  It  is,  however,  often  difficult  to 
decide  the  nature  of  the  abnormalities 
from  the  descriptions  of  them  we  possess, 
and  a  comparison  of  the  frequency  with 
which  they  have  been  found  by  various 
investigators  is,  therefore,  of  no  interest. 
Contraction  of  the  meatus  would  seem 
to  be  the  abnormality  most  frequently 
met  with.  The  greatest  interest,  how- 
ever, attaches  to  the  closing  of  this  pas- 
sage, which  has  been  found  l)y  many  in- 
vestigators without  being  accompanied 
by  any  malformation  of  the  external  ear. 


DEAF-MUTISM.    SYMPTOMS  AND  SEQUELAE.    DIAGNOSIS. 


381 


There  can  be  little  doubt  that  when  the 
meatus  is  closed  by  a  membrane  situated 
close  to  the  external  ear  this  is  due  to 
congenital  malformation;  should  the 
membrane,  however,  be  situated  in  the 
neighborhood  of  the  tympanum,  it  is  pos- 
sible that  the  obstruction  is  the  result  of 
inflammation  in  the  tympanic  cavity.  I 
have,  at  least,  in  two  cases,  observed  such 
a  closing  of  the  external  meatus  of  deaf- 
mutes  resulting  from  scarlatinal  inflam- 
mation, in  the  one  case  on  both  sides,  in 
the  other  on  one. 

As  to  otoscopic  examinations  of  deaf- 
mutes,  these  have  contributed  very  little 
to  the  pathogenesis  or  etiology  of  deaf- 
mutism.  Such  investigations  have  been 
published  by  various  authors,  whose  re- 
searches, in  spite  of  the  care  which  has 
been  bestowed  upon  them,  have  lead  to 
very  little  result;  in  fact,  the  various 
authors  differ  very  considerably  in  the 
results  obtained.  The  difference  ob- 
served in  the  results  of  examinations  of 
normal  children  and  pupils  at  deaf-and- 
dumb  asylums  lies  in  the  greater  fre- 
quency with  which  the  abnormalities 
found  appeared  in  deaf-mutes,  and  not 
in  the  nature  and  kind  of  these  abnor- 
malities. All  investigators  who  have 
classified  the  deaf-mutes  examined  by 
them  according  to  the  nature  of  their 
deafness  (congenital,  acquired,  or  doubt- 
ful) agree  that  the  otoscopic  examina- 
tion of  the  drum-heads  in  cases  of  con- 
genital deafness  yields  a  negative  result 
more  frequently  than  in  cases  of  acquired 
deafness,  the  latter  more  frequently  ex- 
hibiting destructive  inflammatory  proc- 
esses or  the  traces  of  such. 

Abnorm.\lities  of  the  Mucous  Mem- 
BR.^NES  AD.TACENT  TO  THE  Eau. — Ca- 
tarrhal changes  of  the  mucous  mem- 
branes of  the  nose,  naso-pharynx,  and 
pharynx  have  been  frequently  observed. 
These  changes    have    most    frequently 


taken  the  form  of  hypertrophy  of  the 
whole  mucous  membrane,  or  of  the  aden- 
oid tissue  (adenoid  vegetations,  hyper- 
trophy and  hyperplasia  of  the  tonsils), 
less  frequently  the  form  of  atrophy 
(ozsena,  atrophic  catarrh  of  the  naso- 
pharynx and  pharynx).  The  frequency 
with  which  catarrhal  changes  of  the  up- 
per air-tract  has  been  observed  by  inves- 
tigators differs  greatly.  The  cause  is 
doubtless  to  be  sought  in  the  circum- 
stance that  catarrhal  diseases  of  the  nose, 
naso-pharynx,  and  phar3Tix  appear  with 
varying  frequency  in  different  countries 
and  in  different  classes  of  society,  as  cli- 
mate, mode  of  living,  clothing,  hygienic 
conditions,  etc.,  as  is  well  known,  play 
an  important  part  in  the  appearance  of 
catarrh  in  the  air-passages.  The  results 
of  such  examinations  of  deaf-mutes  will, 
therefore,  first  be  of  use  in  judging  of  the 
relation  of  such  affections  to  deaf-mut- 
ism, when  we  possess  information  as  to 
the  frequency  with  which  catarrhal  dis- 
eases of  the  upper  air-passages  appear  in 
normal  subjects  of  the  same  age  and 
living  under  the  same  conditions  as  the 
deaf-mutes  from  which  to  draw  com- 
parison. It  seems,  however,  to  be,  be- 
yond doubt,  that  deaf-mutes  suffer  with 
great  frequency  from  adenoid  vegeta- 
tions of  the  naso-phar}Tix. 

Abnormalities  of  the  Eye. — Al- 
though we  find  several  notices  of  abnor- 
malities of  the  eyes  of  deaf-mutes,  it  is 
often  difficult  to  decide  whether  these 
are  accidental  phenomena  or  connected 
etiologically  with  deaf-mutism.  Among 
the  abnormalities  of  the  latter  category 
may  be  mentioned  retinitis  pigmentosa, 
various  malformations  of  the  eye; 
atrophy  of  the  bulb  caused  by  panoph- 
thalmia, a  result  of  the  same  acute  dis- 
ease as  caused  the  deafness;  finally  syph- 
ilitic interstital  keratitis. 

Diagnosis.  —  Although     deaf-mutism 


382 


DEAP-irUTISlI.    DIAGNOSIS. 


from  a  theoretical  point  of  view  is  not  a 
very  distinctly-defined  condition,  still 
the  majority  of  cases  are  easily  recog- 
nized. The  question  whether  a  person  is 
a  deaf-mute  or  not  must,  according  to 
what  has  been  laid  down  in  the  fore- 
going pages,  be  principally  decided  by 
examinations  as  to  the  function  of  the 
auditory  nerve.  If  this  is  entirely  sus- 
pended, or  so  reduced  that  speech  can- 
not be  heard,  and  if  the  history  of  the 
case  proves  that  this  condition  dates  from 
birth  or  infancy,  then  the  subject  must 
be  regarded  as  a  deaf-mute.  We  are  also 
justified  in  applying  this  term,  as  has 
already  been  pointed  out,  even  where 
there  exists  some  power  of  speech  either 
acquired  by  special  means  of  instruction 
or  where  the  deaf-mutism  has  appeared 
at  a  more  advanced  age,  retained  to  a 
greater  or  less  extent.  The  circumstance 
that  the  pathological  condition  called 
deaf-mutism  is  based  upon  a  symptom, 
the  extent  of  which  cannot  be  measured 
with  any  degree  of  certainty,  but  which, 
nevertheless,  is  decisive,  naturally  causes 
arbitrary  decisions  in  some  cases,  which 
decisions  generally  depend  upon  purely 
practical  considerations.  In  other  words, 
there  are  persons  as  to  whom  it  is  difficult 
to  say  with  certainty  whether  they  are 
deaf-mutes  or  not.  Such  are  persons  who 
can  hear  the  human  voice  to  a  certain 
extent,  and  who  consequently  learn  to 
articulate  by  the  aid  of  special  methods 
of  education,  or  such  as  have  lost  the 
power  of  hearing  so  late  that  they  have 
retained  the  power  of  speech,  although 
their  voice  is  always  somewhat  peculiar. 
Such  persons  are,  however,  but  few  in 
number,  and  consequently  the  diiTiculty 
in  diagnosing  deaf-mutism  mentioned 
here  is  of  very  slight  practical  impor- 
tance. 

Of  much  greater  importance  are  the 
difficulties     which     present    themselves 


when  the  person  in  question  is  an  infant. 
It  must,  however,  be  pointed  out  that 
the  term  "deaf-mute"  is  incorrect  when 
applied  to  children  under  a  year  old,  as 
no  children  can  speak  at  that  age.  It 
would  seem,  indeed,  that  great  caution 
must  be  observed  in  drawing  the  con- 
clusion that  deaf-mutism  will  necessarily 
be  the  result  of  even  total  deafness  ob- 
served during  the  first  year  of  infancy, 
since,  according  to  the  experience  of 
many  etiologists  there  are  some  children 
who  are  unable  to  react,  or  who  react 
very  slowly,  to  sounds  during  the  first 
year  of  infancy,  but  whose  hearing,  nev- 
ertheless, when  older,  is  perfectly  normal. 
In  any  case  it  is  extremely  difficult  to 
arrive  at  any  decided  opinion  whether 
an  infant  possesses  the  power  of  hearing 
or  not,  and  especially  as  to  what  degree 
of  hearing  it  possesses,  and,  as  a  rule,  the 
younger  the  child,  the  greater  is  this  dif- 
ficulty. The  reason  is,  doubtless,  that 
the  sound-conducting  apparatus  of  in- 
fants is  not  complete  at  birth.  The  ex- 
ternal meatus  and  the  tympanic  cavities 
are  transformed  after  birth  from  cavities 
filled  with  cellular  tissue  to  pneumatic 
cavities.  It  was  formerly  supposed  that 
infants  did  not  react  to  sound,  but  it  has 
been  proved  that  this  is  not  the  case, 
even  with  newborn  infants,  and  infants 
can  also  perceive  musical  notes.  Even 
in  the  second  half  of  the  first  year  of 
childhood  it  is,  however,  very  difficult  to 
decide  whether  the  power  of  hearing  ex- 
ists or  not.  No  great  confidence  can  be 
attached  to  the  statements  of  a  child's 
friends  as  to  its  having  heard  certain 
sounds,  as  the  vibrations  of  the  air  caused 
by  certain  sources  of  sound  may  produce 
efTects  upon  the  sensory  nerve  wliich  may 
be  mistaken  for  the  result  of  vibrations 
of  air  acting  upon  the  auditory  nerve. 
It  is,  therefore,  of  the  greatest  impor- 
tance, in  experimenting  with  the  hearing 


DEAF-MUTISM.     DIAGNOSIS. 


383 


of  infanta,  to  make  use  of  such  sources  of 
sound,  or  to  make  use  of  them  in  such 
a  manner,  that  only  the  vibrations  of 
sound  produced  can  be  perceived.  Loud 
dinner-bells  are  suitable  for  this  pur- 
pose; the  so-called  watchman's  whistle, 
Galton's  whistle,  clapping  of  hands,  and 
the  firing  of  small  pistols,  which  the 
child  should  not  be  allowed  to  see.  If 
the  child  reacts  to  these  sounds  it  will 
blink  its  eyes  or  exhibit  either  joy  or 
fear. 

Should  the  results  of  such  experiments 
be  negative,  it  is  not  necessary,  as  before 
mentioned,  to  conclude  that  the  child 
will  become  a  deaf-mute.  After  the  com- 
pletion of  the  first  year  of  infancy,  how- 
ever, the  older  the  child,  the  greater  the 
importance  which  must  be  attached  to 
such  negative  results.  After  that  period 
we  may  look  for  another  symptom  to 
help  us  in  our  diagnosis,  viz.:  the  ab- 
sence of  speech.  This,  too,  may  be  de- 
lusive, as  some  children,  although  in  full 
possession  of  normal  powers  of  hearing 
and  intellect,  do  not  begin  to  speak  at  the 
end  of  their  first  year,  but  later,  some- 
times much  later.  The  cause  may  be 
some  hidden  condition  or  constitutional 
disease;  for  instance,  rickets. 

Another  condition  which  may  be  mis- 
taken for  deaf-mutism  is  simple  mutism 
(aphasia)  uncomplicated  with  deafness  or 
idiocy.  This  abnormality,  which  is  not 
at  all  rare  in  adults  as  the  result  of  cer- 
tain brain  diseases,  is  but  seldom  con- 
genital or  acquired  in  infancy,  at  least, 
there  are  but  few  references  to  it  in  lit- 
erature. This  form  of  aphasia  must,  ac- 
cording to  some  authors,  be  regarded  as 
the  result  of  a  disease  which  is  localized 
in  the  central  nervous  system,  causing 
total  inability  of  speech  in  the  person 
afTected,  or  inability  to  speak  more  than 
a  few  indistinct  words.  This  infantile 
aphasia,  which  seems,  as  a  rule,  to  be 


congenital,  differs  from  the  mutism  of 
deaf-mutism,  principally  inasmuch  as  it 
is  not  accompanied  by  deafness,  and 
often,  also,  in  the  subject  affected  being 
able  to  produce  certain  words  or  sounds 
resembling  words,  which  are  always  em- 
ployed in  attempts  at  speech.  Aphasia 
accompanying  feeble-mindedness,  imbe- 
cility, or  idiocy  is  a  much  more  frequent 
abnormality,  which  is  still  more  easily 
mistaken  for  deaf-mutism,  especially  in 
such  cases  where  the  imbecility  is  so  con- 
siderable that  the  interest  for  sound  is 
diminished.  In  these  cases,  however,  the 
imbecility,  which  must  be  regarded  as 
the  primary  disease,  will  generally  show 
itself  in  the  patient's  appearance,  move- 
ments, gestures,  etc. 

Hysterical  mutism  may  sometimes 
simulate  deaf-mutism.  It  is,  however, 
generally  accompanied  by  pronounced 
symptoms  of  hysteria,  and  exhibits  itself 
by  the  patient's  making  no  attempts  to 
speak,  or  even  to  articulate.  It  is  gener- 
ally of  short  duration  and  easily  recog- 
nized, the  diagnosis  only  offering  some 
difficulty  in  cases  where  the  mutism  ap- 
pears in  deaf,  hysterical  subjects. 

The  question  whether  deaf-mutism  is 
congenital  or  acquired  is,  doubtless,  that 
which  offers  the  greatest  difficulty  in 
forming  a  diagnosis  of  deaf-mutism.  In 
all  cases,  however,  when  the  deafness  ap- 
pears- after  the  child  has  begun  to  speak, 
or  where  the  immediate  causes  of  deaf- 
ness are  known,  the  diagnosis  is  an  easy 
matter.  If,  on  the  contrary,  the  deaf- 
ness has  made  its  appearance  prior  to  the 
period  at  which  speech  is  generally  de- 
veloped— whether  the  morbid  changes  of 
the  organs  of  hearing  causing  deafness 
are  congenital  or  acquired — a  decision  as 
to  the  fcctal  or  post-fa?tal  origin  of  the 
deafness  is  accompanied  by  groat,  indeed 
often  insurmountable,  difficulties.  In 
such  cases  it  is,  therefore,  of  the  greatest 


384 


DEAF-MUTISM.    ETIOLOGY. 


moment  to  obtain  the  most  explicit  in- 
formation from  the  deaf-mute's  friends, 
especially  the  parents,  who  are  most 
likely  to  be  able  to  give  reliable  informa- 
tion as  to  the  diseases  and  pathological 
conditions  which  exist  in  the  family.  An 
opinion  as  to  the  origin  of  deaf-mutism 
can,  as  has  been  previously  mentioned, 
only  in  exceptional  cases  be  based  upon 
objective  examination  of  the  subject. 
Such  exceptional  cases  are,  for  instance, 
those  in  which  visible  and  pronounced 
malformations  of  that  part  of  the  ear 
which  is  accessible  to  examination  clearly 
indicate  that  deaf-mutism  is  the  result 
of  congenital  changes  of  the  auditory 
organs.  Such  cases  are,  however,  very 
rare.  Malformations  in  other  parts  of 
the  body  also  indicate,  though  with  a 
much  less  degree  of  certainty,  that  the 
condition  in  the  ear  is  congenital;  but 
these  cases  are  rare.  The  objective  ex- 
amination of  the  ear,  in  the  great  ma- 
jority of  cases,  offers  nothing  which  can 
be  relied  upon  with  any  degree  of  cer- 
tainty, since,  on  the  one  hand,  patholog- 
ical changes  of  the  external  and  middle 
ear,  which  may,  according  to  their  na- 
ture, be  acquired  after  birth,  may  very 
well  exist  in  persons  whose  deafness  is 
due  to  congenital  malformations  of  the 
auditory  organ;  while,  on  the  other  hand, 
less-pronounced  congenital  changes  of 
the  external  and  middle  ear  (for  in- 
stance, lesser  degrees  of  microtia  and  ma- 
crotia,  contraction  of  the  external 
meatus,  abnormal  position  of  the  drum- 
head, etc.)  may  very  well  appear  in  per- 
sons with  acquired  deafness. 

A  final  decision  as  to  the  congenital 
or  acquired  origin  of  a  case  of  deaf-mut- 
ism must,  then,  in  the  majority  of  cases, 
be  entirely  based  upon  inquiry,  and,  even 
when  explicit  information  is  obtainable, 
it  is  often  diCTicult  to  arrive  at  a  definite 
opinion.    It  will  be  always  advisable  to 


make  inquiries  whether  the  child's 
speech  has  developed  in  the  same  way  as 
that  of  ordinary  children  of  the  same 
age,  because  non-professional  persons' 
statements  as  to  a  child's  power  of  hear- 
ing are  often  unreliable.  Should  the 
answers  be  in  the  affirmative,  and  should 
it  be  proved  that  the  power  of  speech 
has  been  lost,  or  is  arrested  in  its  devel- 
opment from  some  or  other  cause  (acute 
brain  disease,  scarlet  fever,  measles,  etc.), 
it  may  be  safely  concluded  that  the  deaf- 
mutism  is  of  post-fcetal  origin.  This 
diagnosis  is  also  justified,  though  with 
less  certainty,  when  the  above-mentioned 
causes  have  shown  themselves  during  the 
first  years  of  infancy,  unless,  of  course, 
ample  and  satisfactory  proof  can  be  pro- 
duced that  the  child  has  never  possessed 
the  power  of  hearing,  or  that  the  more 
remote  causes  of  deaf-mutism  (unfavor- 
able social  conditions,  heredity,  consan- 
guinity, etc.)  have  appeared  in  great 
force;  in  such  cases  a  decision  must  re- 
main doubtful.  Should,  however,  the 
possibility  of  the  direct  causes  (scarlet 
fever,  brain  diseases,  measles,  etc.)  be 
excluded,  and  it  is  proved  that  the  child 
never  possessed  the  power  of  speech,  it 
may  be  supposed  that  the  deaf-mutism 
is  the  result  of  congenital  changes  of  the 
organs  of  hearing.  This  supposition  is 
the  more  warranted  the  greater  proof 
there  is  that  the  more  remote  causes  of 
deaf-mutism  have  played  their  part  in 
the  case  in  question. 

Etiology. — The  causes  of  deaf-mutism 
may  be  subdivided  into  two  groups:  (A) 
the  remote  causes,  and  (/?)  the  immediate 
causes. 

(A)  Remote  Causes. — Among  these 
are  to  be  mentioned  principally  natural 
conditions,  unfavorable  social  and  hygi- 
enic conditions,  heredity,  consanguinity 
and  a  few  others  of  minor  importance. 

Natural   Condilinns. — In    considering 


DEAF-MUTISM.    ETIOLOGY. 


385 


the  unequal  distribution  of  deaf-mutism, 
we  are  involuntarily  led  to  the  supposi- 
tion that  this  phenomenon  may  be 
caused  by  varying  natural  conditions, 
among  which  soil  and  elevation  seem  to 
play  an  important  part. 

To  H.  Schmaltz  is  due  the  honor  of 
having  investigated  the  question  of  the 
importance  of  geological  conditions  and 
elevation  in  Saxony  so  thoroughly  that 
his  results  are  entirely  to  be  relied  on. 
In  these  investigations,  which  have  em- 
braced the  minutest  details  which  could 
possibly  be  of  importance  concerning  the 
appearance  of  deaf-mutism,  the  author 
has  weighed  each  separate  point  care- 
fully. His  conclusions  are  as  follow: 
There  is  nothing  to  be  said 'in  favor  of 
the  hypothesis  that  soil,  climate,  or  other 
territorial  conditions  influence  the  deaf- 
mute  rate,  neither  can  the  composition 
of  the  water  be  proved  to  affect  it  in  any 
way,  but  it  is  the  social  and  hygienic 
conditions  which  are  decisive.  Lemcke, 
in  Mecklenburg-Schwerin,  and  Ucher- 
mann,  in  Norway,  were  also  unable  to 
prove  that  geological  conditions  are  a 
cause  of  deaf-mutism. 

Unfavorahh  Social  and  Hygienic  Con- 
ditions.— Almost  all  authors  who  have 
considered  the  question  of  the  connec- 
tion between  deaf-mutism  and  unfavor- 
able social  and  hygienic  conditions,  agree 
in  ascribing  to  them  great  importance  as 
causes  of  deaf-mutism.  The  statistical 
proofs  in  support  of  this  hypothesis  are 
not,  however,  on  the  whole,  very  satis- 
factory. The  best  statistics  are  furnished 
by  H.  Schmaltz,  who  has  come  to  the 
following  conclusions:  "The  industrial 
population,  and  especially  that  part  of 
it  which  is  worst  off  pecuniarily, — in 
fact,  all  who  are  in  danger  of  degenerat- 
ing both  morally  and  physically  on  ac- 
count of  insufficient  means,  or  poverty, 
and  who  consequently  are  unable  or  un- 


willing to  take  the  necessary  care  of  their 
children, — all  such  persons  exhibit  the 
highest  percentage  of  deaf-mutes  among 
their  descendants.  Finally,  when,  in  ad- 
dition to  all  these  unfavorable  condi- 
tions under  which  children  are  born,  they 
are  brought  up  by  a  family  which,  from 
various  reasons,  is,  perhaps,  more  or  less 
degenerated,  and  have  to  undergo  all 
sorts  of  diseases  in  infancy  without  hav- 
ing sufficient  power  of  resistance,  thus 
deaf-mutism  is  an  only  too  common  re- 
sult." On  the  other  hand,  Uchermann 
states  that  in  Norway  unfavorable  social 
and  hygienic  conditions  are  far  from  in- 
creasing the  deaf-mute  rate,  it  being 
higher  among  the  better-situated  classes. 

Ueredity.  —  Opinions  have  differed 
greatly  as  to  the  heredity  of  deaf-mutism, 
the  reason  being  that  not  only  are  the 
laws  which  govern  the  hereditability  of 
pathological  changes  and  diseases  sub- 
ject to  different  interpretations,  and  that 
the  statistics  employed  have  given  dif- 
ferent results,  but  also  that  the  term 
"heredity"  is  used  in  different  ways. 

The  term  "heredity"  is  used  by  many 
authors  to  express  the  frequent  appear- 
ance of  the  same  pathological  condition 
in  two  consecutive  generations,  otlier  in- 
fluences having,  of  course,  been  excluded. 
The  statistics  which  have  been  employed 
in  attempts  to  solve  the  question  of  the 
frequency  with  which  deaf-mutism  ap- 
pears in  two  consecutive  generations 
have  been  based  on  two  diflcrent  meth- 
ods: the  one  calculating  how  often  deaf- 
and-dumb  persons  had  deaf-and-dumb 
parents,  the  other  how  frequently  unions 
where  the  one  or  both  parties  were  deaf 
and  dumb  resulted  in  deaf-and-dumb 
offspring. 

The  first  mode  of  ascertaining  tlio  fre- 
quency with  which  deaf-mutism  appears 
in  two  generations,  consisting  in  discov- 
ering how  often  deaf-and-dumb  subjects 


386 


DEAP-MUTISil.    ETIOLOGY. 


belonging  to  large  groups  of  deaf-mutes 
are  descended  from  deaf-and-dumb  par- 
ents, everjTvhere  gives  the  result  that 
deaf-mutes  very  seldom  have  deaf-and- 
dumb  parents.  This  is  even  the  case 
when  only  congenitaUy  deaf  have  been 
the  objects  of  investigation,  Uchermann, 
for  instance,  finding  in  Xorway  among 
921  deaf-mutes  with  congenital  deafness 
only  2  with  deaf-and-dumb  parents.  This 
seems  to  prove  that  deaf-mutism  is  rarely 
inherited  in  the  strictest  significance  of 
the  term,  or,  as  it  might  also  be  ex- 
pressed, inherited  directly.  It  must,  how- 
ever, be  borne  in  mind  that  marriages 
contracted  by  deaf-mutes  are,  and  es- 
pecially have  been,  comparatively  rare 
in  Europe,  and  also  that  their  fertility 
is  smaller  than  that  of  other  marriages; 
there  can  certainly  be  no  doubt  that  the 
direct  hereditability  of  deaf-mutism  is 
certainly  of  much  greater  importance 
than  might  be  supposed  from  the  above- 
mentioned  statistics. 

This  opinion  is  corroborated  by  sta- 
tistics founded  on  the  second  mode  of 
estimating  the  frequency  with  which 
deaf-mutism  appears  in  two  consecutive 
generations,  viz.:  by  calculating  how  fre- 
quently unions  where  one  or  both  parties 
are  deaf  and  dumb  result  in  deaf-mute 
offspring.  The  European  statistics  of 
this  kind  are  but  few  and  small,  the 
reason  being  mentioned  above,  while  the 
excellent  American  statistics  collected  by 
E.  A.  Fay  are  very  comprehensive,  mar- 
riages contracted  by  deaf-mutes  being  so 
much  more  frequent  in  the  United 
States.  The  principal  results  of  Eu- 
ropean statistics  have  been  that  a  deaf- 
and-dumb  child  was  bom  in  about  every 
thirtieth  or  thirty-first  union  where  one 
party  was  deaf  and  dumb,  and  that  deaf- 
mute  ofTspring  were  much  more  fre- 
quently the  result  of  unions  where  both 
parties  were  deaf  and  dumb.     The  sta- 


tistics published  by  Fay  are  based  on  in- 
vestigations of  over  5000  marriages  con- 
tracted by  deaf-mutes  and  have  given  the 
result  that  over  9  per  cent,  of  these  re- 
sulted in  '"'deaf  oft'spring,  and,  curiously 
enough,  the  marriage  where  both  parties 
were  deaf  did  not  result  more  frequently 
in  deaf  offspring  than  those  where  only 
the  one  party  was  deaf."  Fay  also  found 
that  marriages  of  congenital  deaf  persons 
and  of  deaf  persons  with  deaf  relatives 
gave  a  far  greater  liability  to  deaf  off- 
spring. 

If,  now,  the  term  "heredity"  is  used  to 
express  the  conspicuous  frequency  with 
which  the  same  abnormality  appears  in 
the  same  family,  the  hereditability  of 
deaf-mutism  becomes  still  more  evident. 
The  frequency  with  which  deaf-mutism 
appears  among  the  parents  of  deaf-mutes 
has  been  mentioned  above.  Cases  of 
deaf-mutism  among  the  grandparents, 
great-grandparents,  etc.,  of  deaf-mutes, 
which  should  prove  the  direct  heredity 
per  saltum,  as  it  is  termed,  must  neces- 
sarily be  still  less  frequent,  as  marriages 
between  deaf-mutes  were  very  rare  in 
the  first  half  of  this  century.  If  we,  how- 
ever, look  for  cases  of  deaf-mutism  in 
other  branches  of  the  deaf-mutes'  family- 
tree,  we  find  in  all  statistics  that — con- 
sidering that  deaf-mutism  is  a  compara- 
tively -  rare  pathological  condition  —  a 
great  number  of  deaf-mutes  are  to  be 
found  among  the  uncles,  aunts,  great- 
uncles,  great-aunts,  cousins,  and  second 
cousins  of  deaf-and-dumb  persons.  Ac- 
cording to  European  statistics,  embrac- 
ing a  large  number  of  deaf-mutes,  about 
every  sixteenth  deaf-mute  has  one  deaf- 
and-dumb  relative  among  tlie  category 
al)ovc  mentioned  (parents,  grandparents, 
brothers,  and  sisters  excepted),  the  point 
where  deaf-mutism  most  often  appears 
corresponding  to  generations  co-ordinate 
with  the  parents.    These  statistics  have 


DEAF-MUTISM.    ETIOLOGY. 


387 


also  shown  that  it  is  almost  exclusively 
congenital  deafness  which  plays  a  part 
in  this  respect.  Deaf-mutism,  finally,  is 
to  be  met  with  more  frequently  among 
the  brothers  and  sisters  of  deaf-mutes, 
and  there  are  statistics  as  to  congenital 
deaf-mutes  according  to  which  50  per 
cent,  of  these  had  one  or  more  deaf-and- 
dumb  brothers  or  sisters.  The  appear- 
ance of  deaf-mutism  in  two  or  more 
children  of  the  same  parents  is  very 
characteristic,  and  there  are  few  patho- 
logical conditions  which  show  such  a 
tendency  to  appear  in  the  same  branch 
of  a  family,  there  even  being  cases  on 
record  where  ten  deaf-and-dumb  chil- 
dren were  born  in  the  same  marriage. 


frequency  among  the  relatives  of  deaf- 
mutes  and  with  about  double  the  fre- 
quency among  the  relatives  of  congenital 
deaf-mutes  as  among  the  relatives  of 
deaf-mutes  with  acquired  deafness. 

Their  appearance  is  particularly 
clearly  demonstrated  by  several  genealog- 
ical tables  published  by  Dahl  and  Ueher- 
mann,  of  w^hich  the  one  depicted  below 
is  an  interesting  example. 

[Albinism,  retinitis  pigmentosa,  and 
malformations  are  also  frequently  found 
among  the  relatives  of  deaf-mutes;  these 
anomalies  are  probably  to  be  considered 
as  signs  of  degeneration,  deaf-mutism  it- 
self being  undoubtedly  in  several  cases 
a  degenerative  phenomenon.  These 
anomalies,  however,  might  also  be  con- 


Si  St 

(XDIOTJ  I 


l.±   _L     ,_L 


(—') 


[V.  f  !^  r 


(EPILEn"lt)(llllOT)^.UfiATKj  ' 

I (idiot) 


(Li/N'vricl     (lunhtic;        (it), or)   (BE/iF-MurrJ  I  (pzuF-nuTt) 

^EAF-r-iuTE)      (ochr-fiurc) 


(xbiot) 


.V,  male.     /■.  foiuale. 


Finally,  if  by  heredity  we  understand 
the  frequent  appearance  in  a  family  of 
not  only  one  pathological  condition,  but 
of  several  others  related  to  it  anatomic- 
ally or  etiologically,  we  shall  see  that  he- 
redity is  a  most  important  factor  in  the 
etiology  of  deaf-mutism.  It  is,  namelj', 
proven  by  several  comprehensive  statis- 
tics that  partial  or  total  deafness  due  to 
different  car  diseases  (which  have  not 
led  to  deaf-mutism,  on  account  of  the 
lesser  degree  of  the  loss  of  hearing  or  of 
its  unilateral  appearance,  or  of  its  later 
development  in  life),  insanity,  epilepsy, 
idiocy,  stammering,  and  other  defects  of 
speech,  hysteria,  and  several  other  nerv- 
ous   diseases   appear    with    conspicuous 


sidered  as  "nervous  abnormalities."   HoL- 
OEB  Mygind.] 

The  laws  which  may,  then,  be  sup- 
posed to  regulate  the  heredity  of  deaf- 
mutism  are  difficult  of  interpretation, 
and  seem  in  many  respects  to  differ  from 
those  which  relate  to  other  pathological 
conditions  and  diseases.  This  may  be 
accounted  for  by  supposing  that,  as  the 
causes  of  deaf-mutism  in  general  are 
numerous  and  varied,  so  are  also  the 
causes  of  each  individual  case.  The  cir- 
cumstance that  deaf-mutism,  so  far  as 
its  etiology  is  concerned,  must  be  divided 
into  two  distinct  classes,  the  congenital 
and  the  acquired,  the  latter  of  necessity 
including  numerous  cases  in  which  deaf- 


3SS 


DEAF-MUTISil.    ETIOLOGY. 


ness  is  to  be  traced  to  accidental  causes, 
is  alone  sufficient  to  render  the  interpre- 
tation of  the  laws  of  heredity,  by  the 
help  of  investigations  ■which  embrace 
deaf-mutes  in  general,  of  the  greatest 
difficulty.  When  we  add  to  this  that, 
although  the  importance  of  heredity  in 
deaf-mutism  is  undoubted  and  consider- 
able, there  are  other  factors  of  at  least 
equal  importance,  and  that  there  is  much 
which  tends  to  neutralize  the  transmis- 
sion of  morbid  tendencies  (favorable  so- 
cial conditions,  crossed  marriages,  etc.), 
it  will  be  evident  that  there  is  much 
which  renders  a  just  explanation  of  the 
laws  of  heredity  anything  but  an  easy 
task.  If  we  compare  deaf-mutism  with 
haemophilia,  which  it  resembles  so  far  as 
heredity  is  concerned,  we  shall  see  how 
correct  the  above  statements  are.  Hsemo- 
philia — which,  like  deaf-mutism,  may 
pass  over  several  generations  and  accu- 
mulate in  a  single,  being  also  most  fre- 
quent among  males  and  in  the  children 
of  fruitful  marriages— is,  etiologically, 
but  little  complicated,  partly  because  it 
is  not  related  to  any  other  anomaly,  and 
partly  because  heredity  is  the  governing 
cause.  With  deaf-mutism  it  is  very  dif- 
ferent. It,  too,  may  accumulate  in  single 
generations,  being  most  frequent  in 
brothers  and  sisters  and  much  less  fre- 
quent in  the  older  generations.  In  these, 
however,  there  can  be  found  a  compara- 
tively large  number  of  cases  of  partial 
or  total  deafness,  insanity,  epilepsy,  etc., 
which  seems  to  indicate  that  deaf-mutism 
is,  in  many  cases,  a  combined  result  of 
the  transniission  of  various  influences. 
These  influences  fall  into  two  groups: 
those  which  originate  in  ear  diseases,  and 
those  which  originate  in  nervous  disease 
in  the  family.  Now,  as  the  morbid 
anatomy  of  deaf-mutism  proves  that  in 
the  majority  of  cases  the  deafness  caus- 
ing deaf-mutism  arises  from  altmrmnli- 


ties  of  the  nervous  parts  of  the  auditory 
organ, — the  labjTinth, — there  is  reason 
to  suppose  that  in  many  cases  deaf-mut- 
ism is  caused  by  the  transmission  of  the 
above  dual  influences  through  the  par- 
ents. Supposing  this  hypothesis  to  be 
correct,  our  knowledge  of  the  laws  of 
heredity  in  deaf-mutism  assumes  at  once 
a  more  distinct  form,  though  we  cannot 
ever  expect  it  to  be  as  clear  as  it  is,  for 
instance,  in  regard  to  the  laws  which 
govern  liDsmophilia,  for,  as  above  men- 
tioned, the  causes  of  deaf-mutism  are 
too  numerous  and  varied.  Even  twins, 
who  would  seem  to  be  exposed  to  exactly 
the  same  influences  during  fcetal  life,  are 
sometimes  the  one  a  deaf-mute,  the  other 
a  normal  subject. 

Consanguinity. — The  question  of  the 
importance  of  consanguinity  as  a  cause 
of  deaf-mutism  has  been  a  fruitful  sub- 
ject of  discussion.  The  first  decidedly- 
expressed  opinion  upon  this  topic  ap- 
peared in  1846,  when  Meniere  and  Puy- 
bonnieux,  who  were,  respectively,  med- 
ical attendant  and  teacher  at  the  State 
Deaf  and  Dumb  Institution  in  Paris, 
laid  great  stress  upon  the  important 
part  which  consanguinity  played  in 
deaf-mutism,  without,  however,  produc- 
ing statistics  in  support  of  their  theory. 
Such,  however,  appeared  shortly  after  in 
the  returns  of  the  Irish  census  of  1851, 
which  was  the  first  to  include  this  ques- 
tion in  its  rubrics,  and,  from  the  results 
thus  obtained,  Wilde  came  to  the  con- 
clusion that  "among  the  predisposing 
causes  of  mutism  the  too-close  consan- 
guinity of  parents  may  be  looked  upon 
as  paramount."  Vulliet,  Landes,  Chaza- 
rain,  Bemiss,  Ilowe,  Dahl,  Boudin, 
Mitchell,  and  the  undaunted  defender  of 
the  doctrine  of  consanguinity,  Devay, 
were  all  in  favor  of  the  importance  of  this 
factor  in  the  etiology  of  deaf-mutism, 
while  Bourgeois,  P6rier,  Iluth,  Voisin, 


DEAF-MUTISM.    ETIOLOGY. 


389 


and  G.  Darwin  were  more  or  less  op- 
posed to  the  hypothesis  that  consan- 
guineous marriages  predispose  to  degen- 
eration in  the  offspring,  deaf-mutism  be- 
ing generally  the  principal  object  of  their 
arguments.  Statistical  information  as  to 
the  frequency  of  consanguinity  among 
the  parents  of  deaf-mutes  has  also  been 
forthcoming,  the  frequency  with  which 
deaf-mutes  are  reported  as  being  born  in 
consanguineous  marriages  varying  from 
1.6  to  9.4  per  cent.,  while  the  percentage 
for  deaf-mutes  with  congenital  deafness 
varies  from  2.8  to  23.0  per  cent. 

It  will  be  seen,  then,  that  statements 
as  to  the  frequency  with  which  deaf- 
mutes  are  born  in  consanguineous  mar- 
riages differ  considerably.  This  can 
most  naturally  be  explained  as  resulting 
from  various  circumstances.  To  begin 
with,  such  marriages  vary  in  frequency 
in  different  countries;  thus,  in  Prussia 
they  form  only  0.8  per  cent,  of  all  mar- 
riages; in  France  1  to  2  per  cent.;  and  in 
England  3  per  cent,  at  the  outside;  in 
Denmark  3  to  4  per  cent.,  in  Saxony  4, 
and  in  Norway  over  G.65  per  cent.  Fur- 
ther, there  is  no  doubt  that  the  frequency 
of  consanguineous  marriages  differs  in 
the  different  confessions  and  classes  of 
society,  in  cities,  and  in  the  country,  and 
liere,  also,  in  different  districts.  It  must 
also  be  observed  that  the  various  statis- 
tics sometimes  embrace  whole  countries, 
sometimes  single  districts,  and  sometimes 
deaf-and-dumb  institutions,  clinics,  etc. 
Tlie  information  in  question  has  also 
been  obtained  in  different  ways;  for  in- 
stance, by  reports,  censuses,  individual 
investigations,  etc.,  and  finally  the  dif- 
ferent authors  liave  included  different 
degrees  of  relationship. 

Although  many  investigators  have 
found  comparatively  few  deaf-mutes 
born  in  consanguineous  marriages,  there 
are  several  circumstances  which  seem  to 


prove  that  consanguinity  is  an  impor- 
tant factor  in  the  etiology  of  deaf-mut- 
ism.   They  are  the  following: — 

Several  statistical  reports,  the  relia- 
bility of  which  cannot  be  doubted,  are 
to  the  effect  that  deaf-mutes  are  com- 
paratively often  born  of  consanguineous 
marriages,  and  there  seems  to  be  reason 
to  lay  greater  stress  upon  such  positive 
results  than  upon  those  pointing  in  a 
negative  direction. 

All  authors  are  unanimous  in  declar- 
ing consanguineous  origin  to  be  more 
common  among  congenital  deaf-mutes 
than  among  deaf-mutes  in  general.  This 
indicates  that  it  is  deaf-mutes  with  ac- 
quired deafness  who  reduce  the  rate  that 
expresses  the  frequency  with  which  deaf- 
mutes  in  general  are  born  in  consan- 
guineous marriages.  That  consanguinity 
plays  a  part  in  congenital  deafness  only, 
or  almost  only,  may  be  seen  from  the 
circumstance  that  all  authors  who  have 
occupied  themselves  with  this  subject 
have  come  to  the  result  that  deaf-mute 
children  born  of  consanguineous  mar- 
riages are,  in  the  majority  of  cases,  born 
deaf,  while  only  a  small  majority  become 
deaf  after  birth. 

That  consanguinity  is  of  importance 
in  the  etiology  of  deaf-mutism  is  evident 
from  the  circumstance  that  several  au- 
thors have  proved  that,  among  the  mar- 
riages of  which  the  deaf-mutes  are  born, 
the  consanguineous  unions  produce  a 
larger  number  of  deaf-mutes  than  the 
crossed. 

Finally,  several  statisticians  have 
proved  that,  the  closer  the  degree  of  re- 
lationship between  the  parents,  the  larger 
was  the  number  of  deaf-mute  cliildren 
born. 

It  will  be  seen  that  there  are  various 
circumstances  which  clearly  indicate  that 
the  intermarriage  of  relatives  plays  no 
insignificant  part  in  the  etiology  of  deaf- 


390 


DEAF-MUTISM.    ETIOLOGY. 


mutism.  Everything,  however,  tends  to 
prove  that  it  is  entirely,  or  principally, 
in  congenital  deafness  that  consanguinity 
is  an  important  etiological  factor. 

It  is,  however,  imdecided  whether  con- 
sanguinity in  itself  is  a  remote  cause  of 
deaf-mutism,  or  whether  it  is  through 
the  intensiiied  transmission  of  heredi- 
tary, morbid  conditions  or  tendencies 
prevalent  in  a  family  that  it  makes  itself 
felt.  Theoretical  considerations  and  a 
few  lately  piiblished  investigations  in 
Xorway  by  I'chermann  are  strongly  in 
favor  of  the  latter  supposition;  still  it  is 
but  fair  to  say  that  up  to  the  present 
there  have  not  been  many  or  convinc- 
ing facts  brought  forward  in  its  support. 

There  are,  then,  but  few  facts  which 
serve  to  elucidate  the  question  whether 
the  influence  of  consanguinity  upon  deaf- 
mutism  is  direct  or  indirect.  Further  in- 
vestigations of  the  same  nature  will,  per- 
haps, throw  more  light  upon  this  sub- 
ject. The  final  solution  of  the  question 
^^•ill,  however,  in  all  probability,  only  be 
brought  about  by  means  of  information 
as  to  the  family,  supported  by  an  exact 
knowledge  of  the  relatives  of  the  deaf- 
mutes,  and  supplemented  by  their  thor- 
ough objective  examination.  It  is  only 
thus  that  it  will  be  possible  to  find  less 
pronounced,  but  not  on  that  account  less 
important,  abnormalities  in  the  family, 
and  to  discover  with  what  frequency  the 
influence  of  heredity  can  be,  with  cer- 
tainty, excluded  in  consanguineous  mar- 
riages resulting  in  deaf-mute  children. 

There  are,  besides  the  above  men- 
tioned, several  other  remote  causes, 
which  are,  more  or  less  properly,  sup- 
posed to  play  a  part  in  the  etiology  of 
deaf-mutism;  of  these  the  most  impor- 
tant are  the  following: — 

Alcoholism  in  the  Parents. — Although 
the  abuse  of  alcohol  is  extremely  com- 
mon, and  although  we  have  no  informa- 


tion as  to  its  frequency,  on  the  whole; 
still,  several  reports  seem  to  indicate  that 
alcoholism  in  the  parents  plays  some  part 
in  the  etiology  of  deaf-mutism.  Among 
the  most  important  facts  as  to  this  ques- 
tion must  be  mentioned  those  stated  by 
Uchermann  in  Norway,  where,  in  cases 
of  deaf-mutism  of  non-hereditary  origin, 
alcoholism  was  found  with  double  fre- 
quency among  the  parents  of  the  deaf- 
mutes  with  congenital  deafness  than 
among  parents  of  deaf-mutes  irtdth  ac- 
quired deafness.  It  is  at  present  im- 
possible to  form  any  accurate  opinion  as 
to  whether  alcoholism  makes  itself  felt 
by  weakening  the  parents'  constitution, 
or  whether  it  is  an  expression  of  a  nerv- 
ous disposition. 

Syphilis  in  the  Parents. — This  disease 
has,  on  the  whole,  been  found  compara- 
tively seldom  among  the  parents  of  deaf- 
mutes.  This  does  not,  however,  prove 
that  syphilis  plays  no  part  in  the  etiology 
of  deaf-mutism,  for  it  is  often  difficult 
to  discover,  by  questioning,  whether  a 
person  has,  or  has  not  had,  this  disease, 
and  it  is  also  possible  that  investigations 
have,  up  to  the  present,  been  deficient  in 
this  particular.  It  is,  at  all  events,  cer- 
tain that  syphilis  in  the  parents  may 
produce  a  form  of  deafness  in  the  chil- 
dren, appearing  in  the  later  years  of 
childhood,  and  often  leading  to  deaf- 
mutism.  This  form  of  deafness  will  be 
mentioned  more  particularly  under  the 
special  etiology  of  acquired  deaf-mutism. 

Age  and  Difference  in  Age  of  Parents. 
— Meniere  was  the  first  to  draw  atten- 
tion to  these  two  factors  in  the  origin  of 
deaf-mutism,  stating  that,  according  to 
his  experience,  deaf-mutes  were  often  the 
children  of  young  parents,  and  that  such 
marriages  were  frequently  sterile  or  re- 
sulted in  weakly  offsprings.  Later  inves- 
tigations have,  however,  not  confirmed 
this. 


DEAF-MUTISM.    ETIOLOGY. 


391 


Fertility  of  Marriages. — All  authors 
who  have  directed  their  attention  to  this 
subject  agree  that  marriages  producing 
deaf-mutes  are  remarkable  for  their  fer- 
tility. According  to  Uchermann,  this 
may  be  explained  by  supposing  that,  the 
greater  number  of  children  there  are 
born,  the  more  strongly  the  hereditary 
disposition  to  deaf-mutism,  haemophilia, 
etc.,  shows  itself. 

(B)  Immediate  Causes. — According 
to  recent  statistics,  in  about  one-half  of 
the  cases  of  acquired  deaf-mutism  the 
deafness  is  acquired  during  the  first  three 
years  of  infancy,  the  greater  number  of 
cases  falling  in  the  third  (statistics  from 
the  United  States)  or  the  second  (Euro- 
pean statistics)  year  of  life;  then  comes 
the  fourth,  the  first,  the  fifth,  sixth,  and 
so  on. 

Brain  Diseases. — These  play  an  im- 
portant part  in  deafness  acquired  after 
birth  and  resulting  in  deaf-mutism.  The 
Irish  statistics  of  ISSl  show  the  lowest 
figure,  viz.:  11.9  per  cent.;  and  the  Pom- 
eranian report  the  highest,  viz.:  5-1.5 
per  cent.  It  will  be  seen  that  the  im- 
portance of  brain  diseases  in  tho  etiology 
of  deaf-mutism  varies  considerably  in  the 
different  countries;  this  is  not  only  due 
to  the  circumstance  that  the  expression 
"brain  disease"  includes  different  affec- 
■  tions  in  the  different  reports,  but  also 
to  the  varying  intensity  with  which  cer- 
ebral disease  appears  at  different  times 
and  at  different  places.  All  modern  in- 
vestigators agree,  however,  that  brain 
diseases  are  at  present  the  predominant 
cause  of  acquired  deaf-mutism. 

There  can  be  no  doubt  that  the  most 
frequent  brain  disease  leading  to  deaf- 
mutism  is  epidemic  cerebrospinal  menin- 
gitis, the  deleterious  influence  of  which 
has  been  especially  pointed  out  by  lloos. 
We  possess  various  clinical  observations 
of  partial  or  complete  deafness  caused  by 


epidemic  cerebrospinal  meningitis,  and 
post-mortem  examinations  of  persons 
whose  deafness  is  due  to  this  disease  or 
other  similar  brain  diseases,  which  eluci- 
date the  manner  in  which  cerebral  affec- 
tions act  deleteriously  upon  the  infantile 
organs  of  hearing.  The  great  conformity 
which  exists  between  the  changes  in  the 
auditory  organs  caused  by  cerebrospinal 
meningitis  and  changes  declared  to  be 
due  to  inflammation  of  the  brain  in  gen- 
eral, or  to  other  diseases  with  pronounced 
cerebral  symptoms,  authorizes  us  to  sup- 
pose that  the  facts  related  in  the  follow- 
ing paragraphs  hold  good  for  the  ma- 
jority of  cases  of  deaf-mutism  caused  by 
acute  brain  disease. 

Clinical  experience  teaches  us  that  the 
very  considerable  defects  in  hearing 
which  appear  during  epidemic  cerebro- 
spinal meningitis  may  have  a  dual  origin, 
viz.:  inflammation  of  the  middle  ear  or 
an  affection  of  the  labyrinth.  Loss  of 
hearing  from  the  former  cause  is,  how- 
ever, seldom  so  considerable  or  so  lasting 
as  to  result  in  deaf-mutism.  Deafness 
resulting  from  labyrinthine  disease  is 
more  rare,  but,  at  the  same  time,  of  more 
importance,  since  the  loss  of  hearing  is,  as 
a  rule,  very  considerable,  often,  indeed, 
total,  generally  affecting  both  sides,  and 
nearly  always  permanent.  According  to 
iloos  and  Ivnapp,  labyrinthine  deafness 
in  epidemic  cerebrospinal  meningitis 
generally  appears  suddenly,  seldom  grad- 
ually. As  a  rule,  it  appears  in  the  course 
of  the  first  two  weeks,  but  may  also  show 
itself  later;  Knapp  reports  a  case  where 
it  appeared  even  six  weeks  after  the  com- 
mencement of  the  disease. 

Acute  Infections  Diseases. — The  im- 
portance of  this  group  of  diseases  in  the 
etiology  of  deaf-mutism  is  doubtless  at 
present  less  marked  than  that  of  brain 
diseases.  If,  however,  epidemic  cerebro- 
meningitis  is  included  amon?  acute  in- 


392 


DEAF-MUTISM.    ETIOLOGY. 


fectious  diseases, — ^to  which  group  it 
doubtless  belongs, — they  immediately  as- 
sume a  very  prominent  place,  and  there 
can  be  no  hesitation  in  declaring  that  the 
great  majority  of  cases  of  deaf-mutism 
caused  by  acquired  deafness  are  the  re- 
sult of  acute  infectious  diseases.  The 
importance  of  the  parts  played  by  the 
different  diseases  varies  greath^,  as  will 
be  seen,  scarlet  fever  predominating. 

Scarlet  fever  (scarlatina).  This  dis- 
ease has  always  and  in  all  countries  been 
recognized  as  a  very  frequent  cause  of 
infantile  deafness,  and,  consequenth',  of 
deaf-rautism.  The  influence  of  scarlet 
fever  on  deaf-mutism  differs,  however,  in 
different  countries  and  at  different  times, 
which  is  doubtless  due  to  the  varying 
intensity  and  character  with  which  the 
disease  appears.  The  lowest  figures  are 
represented  by  statistics  from  Italy  (1.5 
per  cent.),  the  highest  from  Saxony  (47.6 
per  cent.). 

The  origin  of  deafness  in  scarlet  fever 
has  been  elucidated  by  clinical  research, 
which  proves  that  ear  diseases  caused  by 
scarlet  fever  generally  consist  of  inflam- 
mation of  the  middle  ear,  with  a  marked 
tendency  to  destroy  the  mucous  mem- 
brane and  osseous  walls  of  the  tympa- 
num, and  also  the  auditory  ossicles.  The 
inflammations  of  the  middle  ear,  which 
are  most  frequently  propagated  through 
the  Eustachian  tubes,  but  which  may, 
perhaps,  appear  independently,  are  not, 
as  a  rule,  in  themselves  capable  of  caus- 
ing a  diminution  of  hearing  in  infancy  so 
lasting  and  so  considerable  as  to  result 
in  deaf-mutism,  unless  the  labyrinth  is 
affected.  Scarlatinal  deafness  resulting 
in  deaf-mutism  is  then,  doubtless  in  most 
cases,  due  to  a  partial  or  entire  destruc- 
tion of  the  membranous  contents  of  the 
labyrinth.  This  destruction  is,  in  many 
cases,  caused  1)y  the  propagation  of  the 
inflammation  to  the  internal  ear  either 


through  the  fenestras  (fenestrje  rotundis 
et  ovalis)  or  through  the  vessels  leading 
from  the  tympanum  to  the  labyrinth. 
Some  post-mortem  examinations  of  deaf- 
mutes,  whose  deafness  was  the  result  of 
scarlet  fever,  support  the  former  theory, 
indications  of  an  inflammation  of  the 
middle  ear  being  found,  also  abnormali- 
ties in  one  or  both  fenestra,  doubtless 
the  result  of  an  inflammatory  process. 
On  the  other  hand,  there  are  various 
circumstances  which  indicate  that  scar- 
latinal affections  of  the  labyrinth  may 
appear  independentl}'  of  an  inflamma- 
tion of  the  middle  ear,  or  that,  if  such 
inflammation  had  existed,  it  has  been 
very  slight.  Thus,  for  instance,  it  is 
often  found,  on  otoscopic  examination  of 
deaf-mutes,  who  have  become  deaf  after 
scarlet  fever,  that  the  drum-head  ex- 
hibits but  slight  or  no  abnormalities. 

Measles  (morbilli).  The  reports  relat- 
ing to  the  frequency  of  measles  as  a 
cause  of  deaf-mutism  vary  greatly, 
though  not  so  much  as  was  the  case  with 
scarlet  fever,  which  disease  also  assumes 
a  much  more  prominent  rank  in  the  eti- 
ology of  deaf-mutism;  the  lowest  rate  is 
Wurtemburg  and  Baden  (1.0  per  cent.), 
the  highest  Mecklenburg-Schwerin  (8.3 
per  cent.). 

Among  other  infectious  diseases  which 
now  and  then  cause  deaf-mutism  may 
be  mentioned  the  different  varieties  of 
typhus  (typhoid  fever,  exanthematic  ty- 
phus), diphtheria,  small-pox,  chicken- 
pox,  erysipelas,  dysentery,  influenza, 
ague,  whooping-cough,  mumps,  inflam- 
mation of  the  lungs,  and  rlicumatic 
fever. 

Conslilulional  Diseases. — Of  these  may 
be  mentioned  rickets,  scrofula  and  syph- 
ilis. Altliough  sy])hi]is  is  represented 
in  most  statistics  relating  to  the  causes 
of  deaf-mutism  by  only  a  fraction  or  not 
at  all  in  modern  statistics,  there  can  be 


DEAF-JIUTISM.    MORBID  ANATOMY. 


393 


no  doubt  that  when  inherited  from  the 
parents  it  plays  some  part  in  deafness  ac- 
quired in  infancy  and  resulting  in  deaf- 
mutism.  Inherited  syphilis  may,  as  is 
well  known,  produce  a  peculiar  form  of 
deafness  accompanied  by  certain  ocular 
affections,  which,  it  is  true,  generally 
appears  after  the  age  of  puberty,  but 
which,  however,  also  shows  itself  before 
that  period,  even  as  early  as  the  age  of 
four.  The  circumstance,  however,  that 
hereditary  syphilitic  deafness  often  ap- 
pears without  any  other  marked  symp- 
toms of  syphilis,  and  that  it  is  extremely 
difficult  to  discover  syphilis  in  the  par- 
ents, especially  by  questions  alone,  ex- 
plain why  this  disease  is  so  seldom  no- 
ticed in  the  parents  of  deaf-mutes  in 
hitherto-published  statistics.  It  seems, 
also,  that  acquired  syphilis  may  cause 
deaf-mutism;  but  no  investigators  have, 
up  to  the  present,  touched  upon  this  sub- 
ject. 

Injury  (Trauma).  —  Although  it  is 
probable  that  traumatic  influences,  such 
as  falls,  blows  on  the  head,  etc.,  to  which 
children  are  especially  subject,  are  some- 
times stated  as  being  the  cause  of  deaf- 
mutism  in  cases  of  really  congenital  ori- 
gin, there  is  no  doubt  that  such  causes 
may  produce  deafness  resulting  in  mut- 
ism, as  ear  diseases  of  traumatic  origin 
are  not  at  all  unknown,  even  among 
adults.  Injury  also  is  included  in  the 
causes  of  deaf-mutism  in  nearly  all  the 
more  considerable  statistics,  the  figures, 
however,  being  but  small. 

Morbid  Anatomy. — Although  a  partial 
examination  of  the  auditory  organs  of 
deaf-mutes  during  life-time  is  possible, 
still  it  can  only  embrace  the  peripheral 
parts,  and  there  must  always  be  a  dif- 
ficulty in  deciding  whether  the  morbid 
changes  thus  revealed  are  of  primary  or 
secondary  importance,  or,  indeed,  only 
accidental.    It  is,  therefore,  only  possible 


to  arrive  at  an  intimate  knowledge  of 
the  morbid  changes  causing  deaf-mutism 
and  hence,  at  the  just  comprehension  of 
its  nature,  by  means  of  post-mortem  ex- 
amination. We  have  but  few  reports  of 
such  examinations  dating  earlier  than 
the  commencement  of  this  century,  and 
they  yield  so  little  information  that  we 
can  only  surmise  that  the  examinations 
have  been  incomplete. 

Before  discussing  the  different  parts 
of  the  auditory  organs  in  which  morbid 
changes  have  been  found,  it  must  be  ob- 
served that  several  investigators  have 
found  no  changes  whatever  in  some  of 
the  cases  examined  by  them;  indeed, 
Ibsen's  and  Mackeprang's  investigations 
gave  negative  results  in  no  less  than  one- 
third  of  all  their  cases.  As,  however, 
these  investigations  date  from  a  period 
when  the  microscopical  examination  of 
the  labyrinth  was  but  little  developed, 
and  as  no  mention  is  made  of  an  exam- 
ination of  the  brain  or  of  the  auditory 
nerve,  the  negative  results  arrived  at  lose 
considerably  in  importance,  for  it  is  pos- 
sible that  the  parts  of  the  auditory-  organ 
above  mentioned  have  been  the  seat  of 
undetected  abnormalities. 

Morbid  Changes  of  the  Middle  Ear. — 
If  we  take  a  survey  of  the  pathological 
changes  of  the  middle  ear  which  have 
been  found  in  post-mortem  examina- 
tion of  deaf-mutes,  we  shall  find  that 
such  changes  are  remarkably  frequent. 
It  is  only  exceptionally  that  these  have 
been  the  result  of  malformation;  they 
have,  in  the  majority  of  cases,  owed  their 
presence  to  inflammatory  processes  or  the 
remains  of  such.  These  inflammatory 
processes  have  sometimes  been  of  ca- 
tarrhal nature,  but  generally  suppura- 
tive, in  which  cases  they  have  been  in- 
tense and  destructive.  The  abnormali- 
ties which  are  characteristic  of  the  mor- 
bid anatomy  of  deaf-mutism  have  had 


394 


DEAF-\[UTISM.    MORBID  ANATOMY. 


their  seat  about  the  two  fenestrje,  es- 
pecially in  and  around  the  fenestra  ro- 
tunda, which  has  exhibited  anomalies  in 
not  less  less  than  one-fourth  of  all  the 
dissections  which  yielded  positive  results, 
and  has  in  particular  been  frequently 
closed  by  osseous  masses.  In  the  ma- 
iority  of  cases,  however,  the  abnormali- 
ties of  the  middle  ear  have  been  accom- 
panied by  marked  changes  of  the  inner 
ear. 

Morbid  Changes  of  tlie  Labyrinth. — 
These  have  affected  either  the  whole 
labyrinth  or  only  parts  of  it.  The  so- 
called  entire  absence  of  the  labyrinth 
plays  an  important  part  among  the 
former  class,  partly  on  account  of  its 
comparative  frequency,  and  partly  on  ac- 
count of  its  origin.  The  majority  of 
authors  have  hitherto  regarded  the  ab- 
sence of  the  labyrinth  as  the  result  of  ar- 
rested development.  I  have,  however, 
in  several  of  my  works  proved  that  par- 
tial or  complete  absence  of  the  labyrinth, 
or  of  parts  of  it,  may  be,  and  probably 
most  frequently  is,  caused  by  the  de- 
posit of  osseous  tissue  in  the  labyrinth- 
ine cavity,  which  becomes  thus  more  or 
less  completely  filled  up,  under  which 
process  the  normal  outlines  may  disap- 
pear entirely.  Such  a  formation  of 
osseous  tissue  is  without  doubt  the  re- 
sult of  a  previous  inflammatory  process; 
that  is,  of  an  otitis  intima.  I  have  also 
pointed  out  that  it  is  impossible  to  dis- 
tinguish between  foetal  and  post-fojtal 
morbid  changes  by  post-mortem  exami- 
nation, unless  accompanied  by  exhaust- 
ive and  reliable  information  as  to  the 
cause  and  date  of  the  affection.  From 
the  following  it  will  be  evident  that  the 
deposit  of  osseous  tissue  in  the  cavity  of 
the  labyrinth  is  one  of  the  most  frequent 
labyrinthine  anomalies  found  upon  post- 
mortem examination  of  deaf-mutes,  the 
osseous  mass  sometimes  filling  the  whole 


cavity,  while  sometimes  only  a  section 
exhibits  a  parietal  deposit  which  has 
merely  caused  a  diminution  of  the  cavity 
in  question.  The  most  extensive  forma- 
tions of  osseous  tissue  in  the  labyrinth 
are  apparently  the  result  of  a  post-natal 
otitis  intima.  It  is  interesting  to  ob- 
serve that  various  investigators  have  dis- 
covered siich  osseous  deposit  sometimes 
on  the  one  side  only,  sometimes  on  both, 
some  having  also  found  osseous  tissue  on 
the  one  side,  and  deposits  of  chalk  or 
fibrous  tissue — which  may  also,  as  is  well 
known,  be  the  result  of  inflammatory 
processes — on  the  other  side,  while  both 
the  latter  deposits  have  also  been  fre- 
qiiently  found  in  the  labyrinths  of  deaf- 
mutes  when  there  was  no  formation  of 
osseous  tissue  on  either  side.  Inflam- 
matory and  also  degenerative  processes 
may  leave  other  products  behind  them, 
which  may  appear  in  like  manner  in 
other  parts  of  the  body.  I  would  not, 
however,  imply  that  the  partial  or  total 
absence  of  the  labyrinth  may  not  be  the 
result  of  arrested  development,  which,  on 
the  other  hand,  may  be  due  to  foetal  in- 
flammatory processes.  Still,  it  is  often 
difficult  to  find  proofs  that  such  has  been 
the  origin  of  the  abnormalities  in  indi- 
vidual cases.  A  case  observed  by  Michel 
is,  however,  of  this  nature,  as  the  petrous 
bone  was  entirely  deformed,  and  it  seems 
as  if  we  might  be  justified  in  expecting 
important  malformations  of  the  laby- 
rinth to  be  reflected  in  the  shape  and  ap- 
pearance of  the  petrous  bone.  In  many 
cases  the  inflammatory  process  in  the 
labyrinth  causing  its  partial  or  complete 
destruction  was  secondary  to  an  inflam- 
mation of  the  middle  ear.  According  to 
the  reports  of  several  post-mortem  ex- 
aminations, the  inflammation  of  the  mid- 
dle ear  was  due  to  acute  infectious  dis- 
eases, in  particular  scarlet  fever  and 
measles.    In  conformity  with  the  above, 


DEAF-IIUTISM.    MORBID  ANATOMY. 


395 


it  will  be  seen  that  in  dissections,  in 
whicli  the  complete  or  partial  absence 
of  the  labyrinth  was  discovered,  toler- 
ably well-marked  changes  were  found  in 
the  middle  ear,  consisting,  in  great  part, 
in  the  remains  of  inflammatory  processes; 
and  this  was  true  of  many  of  the  cases 
which  will  be  mentioned  further  on  as 
examples  of  circumscribed  deposit  of 
osseous  substance  in  the  labyrinth.  On 
the  other  hand,  the  absence  of  inflam- 
matory processes  in  the  middle  ear,  or 
the  traces  of  such,  and  in  other  cases  the 
histories  of  the  cases  seem  to  indicate 
that  the  labyrinthine  inflammation  is  not 
of  necessity  propagated  from  the  middle 
ear,  but  that  it  frequently  originates  in 
the  membranes  of  the  brain.  This  is 
especially  probable  in  all  cases  where 
meningitis  is  with  certainty  stated  to  be 
the  cause  of  deafness.  There  is,  perhaps, 
a  third  kind  of  labyrinthine  inflamma- 
tion,— viz.,  primary  inflammation, — 
which  has  been  especially  defended  by 
Voltolini  and  called  after  him  otitis 
intima  of  Voltolini.  The  existence  of 
this  affection  cannot  be  proved  or  dis- 
proved by  arguments  drawn  from  the 
material  here  under  discussion. 

As  far  as  the  seat  of  the  labyrinthine 
changes  in  deaf-mutes  is  concerned,  the 
vestibule  (with  the  exception  of  its 
aqueduct)  is  the  part  of  the  labyrinth 
which  has  been  least  frequently  found 
to  be  the  seat  of  morbid  changes.  The 
reason  is  that  the  vestibule  is,  compara- 
tively speaking,  seldom  found  to  be 
abnormally  changed  on  post-mortem 
examination  of  deaf-born  deaf-mutes, 
anomalies  in  the  two  other  principal  sec- 
tions of  the  labyrinth  being  twice  as 
frequent  in  these  cases.  It  is  also  re- 
markable that  in  no  hitherto-published 
post-mortem  examination  of  a  deaf-mute 
with  acquired  or  congenital  deafness,  or 
where  the  origin  of  the  deafness  is  not 


stated,  has  the  vestibule  been  the  only 
section  of  the  labjTinth  which  has  been 
the  seat  of  abnormalities,  the  other  sec- 
tions being  also  changed  when  this  has 
been  the  case  \^ith  the  vestibule. 

The  semicircular  canals  are  decidedly 
the  portion  of  the  labyrinth  which  is 
most  frequently  the  seat  of  pathological 
changes;  these  are,  indeed,  so  frequent 
here,  that  more  than  one-half  of  the 
dissections  have  yielded  positive  re- 
sults. Indubitable  cases  of  congenital 
malformations  have  been  observed  by 
several  investigators,  but  it  is  question- 
able whether  such  abnormalities  as  the 
union  of  the  two  canals  into  one,  short- 
ening or  lengthening  of  the  canals,  etc., 
are  to  be  regarded  as  of  vital  importance. 
In  not  less  than  one-fifth  of  all  the  dis- 
sections yielding  positive  result  the  semi- 
circular canals  were  the  only  part  of 
the  labyrinth  which  exhibited  morbid 
changes.  In  the  majority  of  cases  in 
which  the  semicircular  canals  have  been 
the  seat  of  abnormalities  they,  or  a  part 
of  them,  have  been  filled  up  by  osseous 
tissues,  or  must  have  been  supposed  to 
have  been  so;  for  instance,  in  the  many 
cases  where  the  reports  simply  mention 
"absence"  of  these  canals.  The  poste- 
rior canal  has  been  most  frequently  at- 
tacked, either  above  or  together  with  the 
superior,  but  principally  together  with 
both  the  superior  and  the  external. 
There  is  no  reason  to  presume  the  fre- 
quent occurrence  of  abnormalities  of  the 
semicircular  canals  to  be  a  frequent  cause 
of  deaf-mutism,  but  only  a  conspicuous 
proof  of  the  frequency  with  which  laby- 
rinthine inflammations  are  a  cause  of 
that  anomaly.  The  abnormalities  dis- 
covered in  the  semicircular  canals  point 
also  in  another  direction  when  it  is  re- 
membered that  it  is  an  approved  fact 
that  disturbances  of  the  equilibrium  are 
verv  common  among  deaf-mutes.  In  this 


396 


DEAT-MUTISM.    MORBID  ANATOMY. 


respect  post-mortem  clinical  observations 
of  deaf-mutes  speak  strongly  in  favor  of 
the  theory  of  the  influence  of  the  semi- 
circular canals  on  the  equilibrium  of  the 
body:  a  theory  which  has  lately  found 
much  support  in  Ewald's  work. 

Morbid  changes  of  the  cochlea  are 
somewhat  more  frequent  than  those  of 
the  vestibule,  and  are  very  equally  di- 
vided between  congenital  and  acquired 
cases  of  deaf-mutism.  In  several  cases 
the  cochlea  was  the  only  part  of  the 
lab}Tinth  which  was  the  seat  of  morbid 
changes;  in  the  great  majority  of  cases, 
however,  other  parts  of  the  inner  ear 
have  been  abnormal,  the  semicircular 
canals  having  been  at  the  same  time  es- 
pecially frequently  the  seat  of  anomalies. 
The  more  or  less  entire  tilling  up  by 
osseous  or  calcareous  masses  is  the  anom- 
aly most  common  to  the  cochlea,  and 
under  this  heading  may  doubtless  be  in- 
cluded all  cases  in  which  the  cochlea  is 
reported  to  be  entirely  absent,  or  in 
which  only  one  or  two  cavities  remained. 
Abnormalities  of  this  nature  are  men- 
tioned in  about  one-eighth  of  all  hith- 
erto-published post-mortem  examina- 
tions. 

Morbid  Changes  of  the  Auditory  Nerve. 
— It  is  a  fact  that,  although  atrophy  and 
degeneration  of  the  auditory  nerve,  or  a 
part  of  it,  are  frequent  in  deaf-mutes, 
they  are  far  from  being  always  present, 
as  believed  by  many,  since  Hyrtl  put 
fonvard   that   supposition,   based   upon 


post-mortem  examinations  performed 
by  him.  As  it  is  to  be  supposed  that 
the  auditory  nerve  of  the  majority  of 
deaf-mutes  examined  post-mortem  has 
been  out  of  function  some  time,  with- 
out there  being  found  any  atrophy  or 
degeneration  in  it  or  its  branches,  it 
would  seem  that  this  nerve  is  not  par- 
ticularly disposed  to  become  atrophied 
or  degenerated  from  inactivity.  The 
correctness  of  this  hypothesis  is  con- 
firmed by  morbid  anatomical  examina- 
tions hitherto  published  of  persons  who 
have  become  deaf  at  a  more  advanced 
age,  which  examinations  all  point  in  the 
same  direction.  The  cases  of  atrophy  or 
degeneration  of  the  auditory  nerve  which 
have  been  found  by  post-mortem  exam- 
inations of  deaf-mutes,  seem,  therefore, 
as  a  rule,  to  be  due  to  some  other  cause, 
and  we  are  obliged  to  regard  them  as  the 
result  of  either  centripetal  atrophy  or 
degeneration  subsequent  to  labyrinthine 
destructive  processes,  or  as  the  expres- 
sion of  a  centrifugal  change  arising  from 
primary  disease  of  the  central  nervous 
system. 

It  is  impossible  as  yet  to  give  any  satis- 
factory reason  why  the  auditory  nerve  in 
some  deaf-mutes  is  atrophied  or  degener- 
ated while  in  others  it  is  not.  The  ques- 
tion will  doubtless  be  cleared  up  by  a 
larger  number  of  post-mortem  examina- 
tions of  deaf-mutes,  accompanied  by  re- 
liable information  as  to  the  origin  of  the 
deafness. 


K.vamination  of  415  young  deaf-mutes,  in  regard  to  primary  cauae  and  to  the 


condition  of  the  ears,  the  nasal  chambers,  and  organs  of  phonation. 
(Med.  News,  Nov.  19,  '92). 

Condition  of  the  Ears. 


Plantic  otitis  media 

Adherent  and   immovable  drum-heads. . 

Very    feebly   movable   drumheads 

Atrophic   drum-heads 

Kngorgement  of  manubrial   vessels   and 
pinkish  tint  of  drum-head 


A.  A.  Bliss 


lup  1. 

(;nm|)2. 

flnHipM. 

Tntl.l 

75 

20 

10 

111 

94 

28 

3 

125 

43 

12 

4 

59 

2 

0 

0 

2 

DEAF-MUTISM.    MORBID  ANATOMY. 


397 


Condition  of  the  Ears  (continued). 


Calcareous  deposits  in  drumhead 

Double  perforations  with  otorrhea 

Single   perforations   with   otorrhoea 

Cicatrized    perforations,    many    of   them 

covered   with   new   membrane 

Double  impactions  of  cerumen 

Single   impactions   of   cerumen 

Atresia  of  external  auditory  meatus.  .  .  . 
Undeveloped    auricles    with    absence    of 

auditory    meatus 

Foreign   bodies 

Desquamative  otitis  e.\terna 

A  slight  trace  of  hearing 

Hearing  on  contact  only 

Fair   hearing 


Mipl. 

Gk.M1i  2. 

Gn.upS. 

Total. 

u 

2 

0 

10 

9 

5 

3 

17 

10 

5 

1 

IG 

32 

13 

3 

48 

U 

5 

0 

19 

15 

7 

2 

24 

2 

0 

0 

2 

1 

0 

0 

1 

G 

0 

0 

6 

4 

0 

0 

4 

0 

17 

2 

25 

02 

G 

10 

73 

0 

2 

0 

2 

Primary  Cause. 


Spotted    fever 43 

Scarlet  fever 66 

Measles   17 

Meningitis    29 

Typhoid  fever 5 

Pneumonia     2 

Diphtheria   2 

Malaria  2 

Small-pox   1 

"Colds"    13 

Convulsions   10 

Black    fever 3 

Traumatism   9 

Spinal  meningitis 5 

Inflammation  of  bowels 2 


Cholera    infantum 1 

Shock     1 

Mumps    1 

Bronchitis    1 

Catarrhal  fever 1 

Sun-stroke    1 

Otitis   media 9 

Whooping-cough     2 


Teething   

Croup 

Eczema    

Unknown  (exclusive  of  137  pupils 
credited  as  being  deaf-mutes  from 
birth)     


Pathological  Conditions  Present. 

^Vfl'-M.  Group  1.  Grm,,, 

Deformities  consisting  of  deviated  septa, 

exostoses,      hypertrophied      turbinals, 

causing  partial  or  complete  occlusion 

of  one  or  both  nares 65  14 

Posterior  hypertrophies  of  turbinals 21  1 

Impactions  of  middle  turbinals  against 

the    septum 14  3 

Synechial    bands    between    the    septum 

and  lower  turbinals 2  2 

Sclerosis   of   mucous   membrane   in    the 

anterior  nares 35  7 

Sclerosis  in  posterior  nares 13  8 

Atrophy  of  nasal  mucous  membrane....  20  2 

General  catarrhal  condition  due  to  vaso- 
motor paresis  without  deformities....  13  3 


Gioiii)3.  Total. 


4 

83 

2 

24 

0 

17 

0 

4 

5 

47 

0 

21 

0 

22 

398 


DEAF-MUTISM.    MOEBID  ANATOMY. 


Pathologicai.  Conditions  Present  (coiilinued). 
Adenoids   in   vault   of   pharynx,   causing     Groiin  l.  Group  2.         Group  3. 

partial  occlusion  of  this  space  or  press- 
ure upon  the  Eustachian  openings. ...  67  14  8' 

Tongue. 

Abnormally-short  frsenum 24  0  1 

Hypertrophy  of  the  lingual  tonsil  worthy 

of  note 12'  1  O 

Palate. 

Abnormally  high,  narrow,  and  Gothic- 
arched   8  0  2 

Deflection   of    raphe    from    median    line, 

most  frequently  to  the  left  side 6  0  0 

Double    uvula 2  0  0 

Relaxed  and  pendulous  soft  palate 2  0  0 

Tonsils. 

Large  tonsils  filling  the  spaces  between 
the  faucial  pillars  of  their  own  sides 
of  the  throat,  but  not  adherent  to 
these  bands,  or  not  causing  serious 
occlusion  or  pressure  upon  surround- 
ing  parts 32  Iti  1 

Tonsils  greatly  hypertrophied,  diseased, 
and  causing  pressure  upon  the  palate 
or  tongue,  and  greatly  occluding  the 
faucial  space 18  5  4 

Adhesion  between  tonsil  and  faucial  pil- 
lars, the  tonsil  being  incapsulated 30  6  5 

Narrowing  of  fauces  by  broad  posterior 
pillars  with  high  attachment  to  the 
pharyngeal  walls 11  0  0 

Pharynx. 

Simple  hypertrophy  of  mucous  follicles.  .23  3                     2 
Sclerosis     of    mucous     membrane     with 

follicular    hypertrophy 9  6                    0 

Simple  sclerosis  of  mucous  meiubrane..            55  20                    5 

Atrophy  of  mucous  membrane 8  11 

Venous  engorgement  worthy  of  note...           22  2                   3 

Larynx. 

Epiglottis  abnormally  depressed 14*  2  0 

"Infantile"    epiglottis 2*  0  0 

Vocal  Bands. 

Apparently  normal  in  color  and  ordinary 
movement 83  63  12 


Total. 
79 


163 


'  Blx  of  tlicHC  wore  in  pupils  between  U  and  22  years  old  j  tlio  other  six  in  pupils  under  H  years  of  ogo. 
'Tliciic  eight  eiiHCH  all  occurred  In  subjects  between  12  and  10  years  old. 
'  Only  four  being  In  pujillfl  under  14  years  of  ago. 
•  Both  being  In  pupllH  over  14  years  of  ago. 


DEAF-MUTISM.     MOREID  ANATOMY. 


399 


Examination  of  175  deaf-and-dumb 
children.  Tested  by  a  large  bell,  a  large 
tuning-fork,  and  the  human  voice.  The 
children  were  found  to  divide  themselves 
into: — 

1.  Those  stone-deaf  or  having  no  aCiial 

hearing, 9 

2.  Those  hearing  vciy   loud  sounds, — 

shouting,  etc.,       .        .        .         .81 

3.  Those  hearing  and  distinguishing  the 

voice  : — 
(a)  Vowels   only,         .         .         .      20  )    gg 
(6)  Consonants  and  words,  .      13^ 


Dlsqualifled     for    testing    be 

youth,  idiocy,  etc.. 
Dumb,  hut  hearing  perl'ectly. 


Of  the  9  totally  deaf,  by  far  the  larger 
number  were  cases  of  congenital  deaf- 
ness. Of  those  who  could  hear  and  dis- 
tinguish the  voice,  much  the  larger  num- 
ber were  cases  of  acquired  deafness. 
The  causes  of  acquired  deafness  were 
found  to  be,  in  half  the  eases,  primary 
disease  or  injury  in  the  brain  or  internal 
ear,  without  apparent  disease  of  the  mid- 
dle or  external  ear.  Measles  and  scarlet 
fever  were  found  responsible  for  13  cases. 
Sixty-one  cases  of  normal  membrane 
were  found  among  the  175  children;  32 
showed  suppurative  disease,  and  nearly 
80  catarrhal  changes.  The  pharynx  was 
diseased  in  most  of  the  cases.  J.  K. 
Love    (Glasgow  Med.  Jour.,  June,  '93). 

Post-mortem  examination  of  the  ears 
of  a  deaf-mute.  The  case  was  that  of  a 
young  man,  aged  IS  years,  who  died  from 
pulmonary  and  intestinal  tuberculosis. 
When  2  Va  years  old  lie  suiTered  from 
scarlatina,  and,  as  a  result,  became  a 
deaf-mute.  In  the  right  ear  the  patho- 
logical conditions  were  confined  to  the 
labyrinth,  and  consisted  of  destruction 
of  its  integral  parts,  the  various  spaces 
having  undergone  ossification.  The 
drum-head  and  tympanum  were  quite 
normal.  The  ligamcntum  annulare  sta- 
pedis and  the  mcmbrana  fcnestrte  ro- 
tunda; were  ossified ;  but  this  process 
was  confined  to  the  sides  adjoining  the  in- 
ner ear.  In  the  left  car  were  found  otor- 
rhoea,  ossification  of  the  spongy  portion 
of  the  pars  petrosa  and  of  the  processus 
mastoideum,     and     ossification     of    the 


membrana  fenestrse  rotundse;    the  liga- 
ment of  the  stapedius  muscle  was  mov- 


Fig.  2. 

Auditory  ntiophy  and  anomalies  of  development  In 

the   nienibianous   labyrinth   of  both   ears 

in  a  case  of  deaf-mutism.    (Seheibe.) 

Fig.  1. — CO,  Corti's  orsraii ;  z,  increased  cells  in  the 
sulcus  spiralis  ;  6,  arrlied  layer  of  cells,  ex- 
tending to  the  llmbus  lamlua)  spiralis  ossesB  ; 
m,  Corti's  membrane. 

Fig.  2, — s.  Stratum  scmilunare  ;  b,  beginning  of 
basilar  membrane;  ;>,  prominentia  spiralis; 
/,  ridge  on  the  stria  vascularis  ;  «,  flat  cells  on 
the  rest  of  the  stria  ;  r,  a  piece  of  Roissncr's 
membrane,  bulged  forward  toward  the  scala 
vcstlbuli ;  Inserted  somewhat  peripherally,  and 
extending,  farther  on,  in  a  thicker  layer  of  cells. 

(ZpiUchria  Tur  Ohr«iih«ilkuDd«.) 

able.  The  inner  ear  showed  no  sign  of 
pathological  fluid  or  new  formations. 
The  surface  of  the  brain  showed  no  ab- 


400 


DEAF-MUTISM.    MORBID  ANATOMY. 


normality.  Broca's  convolution  appeared 
smaller  than  normal.  The  superior  tem- 
poral convolution  of  the  left  side  was 
also  smaller  than  xisual.  The  micro- 
scopical examination  did  not  show  any 
positive  signs  of  abnormality.  These 
cerebral  changes, are  supposed  to  result 
from  atrophy  consequent  upon  the  in- 
activity of  the  parts,  it  being  worthy  of 
note  that  this  left-sided  atrophy  is  asso- 


ness  (field  of  vision)  with  the  instrument 
of  Landolt.  Conclusions:  The  reactions 
to  general  sensitiveness  and  to  pain,  in 
the  deaf-mute,  are  very  little  inferior  to 
the  normal.  In  early  life,  indeed,  there 
is  no  difl'erence  worthy  of  note.  So  also 
with  regard  in  general  to  the  field  of 
vision;  ii  is  normal  both  in  extent  and 
form,  except  for  a  readiness  to  fatigue, 
which  by  itself  is  anything  but  a  serious 


Auditca-y  atrophy  and  anomalies  of  development  in  the  membranous  labyrinth  of  both 
ears  in  a  case  of  deaf-mutism.     {Scheihe.) 

Fig.  .3. — r,  Rosenthal's  canal ;  la,  lamina  spiralis  ossea;  g,  ganglion-cells;  I,  lacuna;  nl,  enter- 
ing nerve-fibres;  nS,  departing  nerve-Hl]res  ;  b,  connective  tissue. 

Fig.  4. — »,  Semilunar  stratum;  c,  crista  splniliB;  6,  basilar  membrane;  co,  Corti'e  organ  baJly 
preserved;  ;;,  prominentia  spiralis ;  br,  Ijridge ;   I,  lacuna  in  tlie  stria  vascularis;  Is,  ridge 
with  attaclimcnt  to  the  lower  part  of  tlie  bridge  ;  m,  rudimentary  Corti  membrane. 
(ZeitHclirift  fiir  Ohronhonkiinde.) 


ciated  with  destruction  of  the  right 
labyrinth.  Conclusion  that  there  is 
good  ground  for  the  belief  that  the 
fibres  of  the  acoustic  nerve  cross  in  the 
brain.     V.  Uehermann  (Annual,  '93). 

Examination  of  the  reactions  for  gen- 
eral and  painful  sensations  in  forty-four 
deaf-mutes  with  the  faradimeter  of 
Edelmen,   and   of  the   retinal   sensitive- 


sign  of  marked  degeneration.  The  sensi- 
tiveness of  the  deaf-mute  evidently  ex- 
presses a  mental  development  of  a  very 
satisfactory  quality,  and  clearly  differ- 
entiates him  from  such  classes  as  the 
criminals,  the  epileptics,  and  the  feeble- 
minded (partial  imbeciles),  not  to  men- 
tion more  marked  forms  of  degeneration. 
In  spite  of  the  absence  of  one  sense,  the 


DEAF-MUTISM.    MORBID  ANATOMY. 


401 


sensitive  zone  of  the  deaf-mute  is  not 
deficient.  Various  stimuli  from  all  the 
sources  in  the  sensorium  reach  his  cortex, 
and  this  is  in  such  condition  as  to  be 
able  to  normally  elaborate  the  stimuli; 
hence  comes  ease  of  perception  and  at- 
tention. All  the  other  sensorial  sources, 
if  exercised,  can  supply  the  want  of  a 
source  so  full  of  ideas  as  is  that  of  hear- 
ing, when  the  centre  is  normal.  This 
fact  should  help  our  judgment  in  form- 
ing the  scientific  diagnosis  of  the  deaf- 
mute.  Deaf-mutism,  by  itself,  does  not 
mean  serious  degeneration.  S.  Ottolenghi 
(Jour,  of  Laryn.,  Jan.,  '9G). 

Case  in  which  there  were  atrophic 
changes  in  the  fibres  of  the  cochlear 
branch  occupying  the  first  whorl,  the 
corresponding  portion  of  Corti's  organ 
being  reduced  to  a  mere  trace,  while  in 
the  upper  whorls  it  was  lower  than  nor- 
mal, the  membrane  being  rolled  up  in 
the  rudimentary  way.  This  and  other 
allied  conditions  indicated  a  congenital 
defect  or  anest  of  development.  A. 
Scheibe  (Arch,  of  Otol.,  vol.  xxiv,  Nos. 
3  and  4,  '97). 

Deaf-mutism  is  the  result  of  aural  dis- 
ease acquired  in  infancy  consecutive  to 
acute  rhinitis.  From  neglect  there  fol- 
lows atrophy  of  the  acoustic  nerves. 
These  cases  would  be  curable  if  the 
nerves  could  be  stimulated  to  proper  de- 
velopment by  vibrations  carried  through 
the  cranial  vault.  Twelve  deaf-mutes 
thus  cured,  but  it  required  several  years. 
The  naso-pharynx  received  particular  at- 
tention; the  drum  was  mobilized  by 
means  of  Politzer's  inflator  and  by  the 
apparatus  of  Delstanche,  the  patients 
also  receiving  oral  instructions.  Acute 
rhinitis  in  children  should  be  carefully 
watched  and  treated.  Verdos  (Annales 
des  Mai.  de  I'Orcille  du  Larynx,  No.  5, 
•97). 

Unchermann  found  in  1885  about  1841 
deaf-mutes  in  Norway,  of  whom  51  per 
cent,  were  hereditary,  and  the  remain- 
ing percentage  were  acquired,  with  the 
exception  of  0.5  per  cent.,  in  whom  it 
could  not  be  determined.  It  is  not  al- 
ways possible  to  determine,  even  by  ex- 
amination after  death.  Most  cases  of 
acquired  deaf-mutism  are  caused  by  dis- 
eases  of  the  labyrinth,  most   of  which 


have  spread   from   the  brain   or  middle 
car.     Mygind,  in  his  work  in  1894,  re- 
ported over  139  cases  in  which  the  mid- 
dle ear  only  was  diseased,  but  he  stated 
nothing  about  the  labyrinth  or  the  his- 
tological examination  of  the  labyrinth. 
Thus,  Matte  could  completely  deny  the 
occurrence  of  deaf-mutism  due  solely  to 
middle-ear  disease.     Two  personal  cases 
in   which   the  middle  ear  only   was  de- 
monstrable   as    a    cause    of    the    deaf- 
mutism.      J.     Habermann     (Archiv     f. 
Ohrenh.,  Bd.  liii,  S.  52-07,  1901). 
Morbid  Changes  of  the  Brain  {Cere- 
Irum). — The  defective  development  of 
the   surface    of   the    third    convolution 
and    of   the    insula   Eeilii    of   the   left 
side  may  be   mentioned   as   an   abnor- 
mality several  times  discovered  in  deaf- 
mutes,  but  which  has  no  causal  rela- 
tion to  deafness.     Eiidinger  and  Wald- 
schmidt  found  this  abnormality  in  sev- 
eral deaf-mutes  who  presented  no  his- 
tory  of  disease,  and   whose   labyrinths 
were  not  examined,  while  other  investi- 
gators found  it  in  two  deaf-mutes  who 
had  both  become  deaf  after  birth,  in  the 
third  year,  after  meningitis  and  scarlet 
fever,  respectively,  and  vrho  both  exhib- 
ited pronounced  abnormalities  in  the  ear. 
The  flattening  of  the  cerebral  convolu- 
tions is  doubtless  due  to  atrophy,  caused 
by  the  inactivity  of  the  parts  of  the  brain 
which  are  known  to  be  the  motor  centre 
of  speech,  on  account  of  the  inactivity 
of  the  muscles  of  speech.     In  the  two 
latter  cases,  also,  there  was  information 
proving  that  the  deaf-mutes  in  question 
had  never  learned  to  speak. 

Case  of  deaf-mutism,  in  an  adult, 
found  at  the  autopsy  to  have  been  due 
to  symmetrical  lesions  in  the  two  tem- 
poral lobes.  The  entire  cranial  capacity 
was  less  than  normal,  the  brain  weigh- 
ing 935  grammes  (30  ounces),  and  the 
left  hemisphere  was  almost  one-fourth 
smaller  by  weight  than  the  right.  The 
first  and  second  temjioral  convolutions 
were  destroyed,  normal  being  replaced  by 
cicatricial  tissue,  while  the  third  convo- 


403 


DEAP-MUTISM.    PROGNOSIS.    TREATilENT. 


lutions — the  supramarginal  and  the 
angular  gyri — were  atrophied  and  scle- 
rosed. The  convolutions  of  the  island  of 
Reil  were  intact  on  the  right,  but  largely 
destroyed  on  the  left;  acoustic  nerves 
very  thin.  The  patient  presented  notable 
deficiency  of  intellect,  with  absolute 
deafness  and  dumbness.  She  possessed 
a  certain  amount  of  intelligence,  how- 
ever, and  could  comprehend,  to  a  certain 
degree,  mimetic  language.  No  motor 
paralysis  of  trunk  or  limbs  existed,  nor 
was  there  any  defect  present  in  vision  or 
cutaneous  sensibility.  Seppilli  (Alienist 
and  Neurologist,  Apr.,  '93). 

If  we  cast  a  retrospective  glance  over 
the  foregoing  facts  it  will  be  seen,  first, 
with  regard  to  the  nature  of  the  morbid 
changes  met  with  in  the  hearing  organs 
of  deaf-mutes,  that  they  do  not  differ,  so 
far  as  their  quality  is  concerned,  from 
those  generally  found  in  ear  diseases,  but 
that  the  difference  must  be  rather  sought 
in  the  intensity  and  extent  of  the  morbid 
processes.  The  abnormalities  found  in 
deaf-mutes  may,  at  least  in  a  great 
number  of  cases,  be  most  naturally  inter- 
preted as  being  the  results  of  intense 
and  wide-spread  inflammatory  processes. 
This  is  particularly  evident  in  cases  re- 
ferring to  deaf-mutes  who  had  become 
deaf  after  birth.  It  will  further  be  seen 
that  the  abnormalities  found  in  eases  of 
congenital  and  acquired  deafness  often 
present  exactly  the  same  appearance;  so 
that  in  many  cases  it  is  impossible  to 
decide,  from  the  post-mortem  examina- 
tion alone,  whether  the  changes  are  of 
foetal  or  post-foatal  origin.  It  is,  thus, 
evident  that  the  formerly  accepted  opin- 
ion, that  deaf-mutism  arising  from  con- 
genital deafness  was  due  to  congenital 
malformations  of  the  auditory  organs, 
has  not  been  confirmed,  since  abnormali- 
ties which  are  the  indubitable  expression 
of  such  malformations  are  but  seldom 
met  with.  So  far  as  the  seat  of  the  abnor- 
malities was  concerned,  it  was  found  that 


these  were,  as  a  rule,  bilateral,  but  have 
often  differed  greatly  on  either  side,  both 
as  to  character  and  localization,  and  es- 
pecially as  to  intensity.  The  few  cases 
in  which  the  principal  abnormalities 
were  confined  to  the  one  side,  while  the 
other  was  normal  or  only  the  seat  of 
unimportant  anomalies,  must,  for  the 
present  at  least,  be  looked  upon  with  sus- 
picion. Finally,  it  has  been  proved  that 
the  middle  ear  has  very  frequently  been 
the  seat  of  changes,  accompanied,  as  a 
rule,  by  important  abnormalities  in  the 
inner  ear.  These  were  most  frequently 
situated  in  the  semicircular  canals,  least 
frequently  in  the  vestibulum,  and  were  to 
be  considered  as  the  principal  cause  of 
deafness.  The  auditory  nerve  in  many 
cases  exhibited  signs  of  atrophy  and  de- 
generation and  a  few  other  abnormali- 
ties, while  in  a  considerable  number  of 
cases  no  changes  were  visible.  In  some 
few  cases  the  brain  deviated  somewhat 
from  the  normal. 

Deaf-mutism  is,  therefore,  from  an 
anatomical  point  of  view,  in  most  cases 
to  be  considered  as  a  result  of  an  abnor- 
mality of  the  labyrinth. 

Prognosis. — There  is  no  doubt  that  the 
prognosis  of  the  deafness  which  is  the 
cause  of  deaf-mutism  is  highly  unfavor- 
able, still  there  exist  some  well-authenti- 
cated cases  of  deaf-mutes  whose  power  of 
hearing  has  been  at  least  partially  re- 
stored. 

Treatment. — It  is  as  yet  difficult  to 
say  in  what  cases  treatment  is  indicated, 
as  we  have  not  reached  further  than  to 
the  first  experiments  in  that  direction. 
I  have  latterly  endeavored  to  act  accord- 
ing to  the  following  rules  when  deaf- 
mutes  have  been  brought  to  me  for  treat- 
ment: Treatment  is  most  decidedly  in- 
dicated when  the  deaf-mute  suffers  from 
suppurative  inflammatory  processes  of 
the    middle    ear.      Treatment    can,    at 


DEAF-MUTISM.    TREATMENT. 


403 


least  in  such  cases,  remove  or  diminish 
the  danger  which  always  attaches  to  sup- 
puration of  the  midde  ear.  Uchermann's 
experience  also  proves  that  the  defects 
in  the  power  of  hearing  may  be  dimin- 
ished in  cases  of  this  nature.  Treatment 
is  also,  I  think,  indicated  in  cases  in 
which  there  are  some  traces  of  the  power 
of  hearing,  and  especially  when  this 
power  exists  with  varying  intensity,  and 
where  there  are  also  symptoms  of  ca- 
tarrhal conditions  in  the  middle  ear  (ca- 
tarrhal changes  of  the  membrana  tym- 
pani,  retraction  of  the  manubrium  of  the 
malleus,  occlusion  of  the  tubaa,  etc.);  also 
catarrh  of  the  mucous  membranes  ad- 
jacent to  the  ear,  especially  when  there 
also  exist  hypertrophy  of  the  adenoid  tis- 
sue in  the  naso-pharyngeal  cavity.  If 
the  cranio-tympanic  conduction  still 
exists,  the  chances  in  this  group  of  cases 
seem  more  favorable  still.  In  cases  of 
catarrh  of  the  middle  ear  and  adjacent 
mucous  membranes,  where  no  signs  of 
hearing  can  be  discovered  after  repeated 
examination,  I  have  also  attempted  treat- 
ment; though  I  am  not  certain  that  such 
a  course  gives  any  hopes,  as  my  experi- 
ence has  not  been  very  favorable  in  this 
group  of  cases. 

Useful  hearing  obtained  in  a  deaf- 
'  mute  aged  19  years.  On  examining  the 
nasopharynx  a  dense  band  of  hyper- 
trophy in  each  RosenmtlUer  fossa  was 
found.  The  hypertrophied  tissue  was 
removed,  and  her  ears  were  regularly 
politzerized.  Tliis  was  followed  by  a 
very  great  improvement  in  hearing,  so 
that  words  distinctly  spoken  at  the  dis- 
tance of  a  few  feet  in  the  ordinary  voice 
could  be  understood.  Gibson  (Aus- 
tralasian Med.  Gaz.,  Oct.,  1900). 

To  all  the  above-mentioned  groups  the 
indications  are  the  same,  whether  the 
deafness  is  congenital  or  acquired.  Va- 
rious circumstances,  which  have  been 
pointed  out  in  the  foregoing  pages,  indi- 
cate that  total  deafness  resultinsr  from 


acute  infectious  diseases,  especially  cere- 
brospinal meningitis  and  scarlet  fever, 
and  accompanied  by  slight  catarrhal 
changes,  is  due  to  a  constant  labyrinth- 
ine disease  which  defies  all  treatment. 

So  far  as  the  nature  of  an  ultimate 
treatment  is  concerned,  it  must  be  ob- 
served that  general  and  special  otological 
principles  must  be  used  as  guides,  and 
the  treatment,  in  the  majority  of  cases, 
should  be  local. 

Treatment  in  other  than  the  above- 
mentioned  cases  of  deaf-mutism  is,  of 
course,  justified  when  it  is  not  accom- 
panied by  any  danger  to  the  patient, 
when  it  is  indicated  by  otological  princi- 
ples, and  when  it  is  certain  that  the  ana- 
tomical cause  of  the  deafness  is  not  situ- 
ated in  the  brain.  It  is  for  the  future  to 
show  what  chance  of  improvement  such 
cases  have. 

Urbantschiseh's  treatment  is  also 
worthy  of  mention.  It  consists  in  regu- 
lar acoustic  exercises,  intended  either  to 
awaken  or  improve  the  power  of  hear- 
ing in  deaf-mutes;  and  there  is  every 
reason  to  look  forward  to  more  exhaust- 
ive information  as  to  the  results  of  such 
treatment  with  considerable  interest. 

Instrument  intended  to  facilitate 
treatment  by  Crelle's  auditory  exercises, 
and  produce  the  voice  automatically  by 
means  of  clock-work  with  an  intensity 
which  is  subject  to  regulation.  It  con- 
sists of  a  horizontal  cylinder  run  by 
clock-work,  on  which  wax  is  spread  for 
receiving  the  registration.  An  apparatus 
placed  in  front  of  the  cylinder  bears  a 
membrane  with  a  rounded  style,  to 
which  is  attached  a  little  special  micro- 
phone, with  micrometric  vise,  springs, 
and  levers.  An  electric  current  is  passed 
into  the  special  microphone,  and  into  a 
receiver  like  that  of  a  telephone.  When 
the  receiver  is  brought  to  the  ear.  the 
words,  or  sounds,  repeated  by  the  phono- 
graph are  heard  with  an  intensity  which 
can  be  regulated  at  will  by  increasing 
the  number  of  cells.     By  increasing  the 


4^04  DEAF-MUTISM. 

force  of  the  current  the  sounds  can  be 
made  so  intense  as  not  to  be  endured 
without  violent  pain.  Dussaud  gives  the 
receiver  of  a  similar  instrument  devised 
by  him  to  the  deaf  of  all  kinds  and  de- 
grees. He  is  said  to  be  able  to  make 
even  deaf-mutes  keep  time  to  music  and 
distinguish  vowels  and  words.  Each 
cylinder  can  repeat  10,000  times  what  it 
contains  without  any  alteration.  Re- 
engraved,  this  can  be  repeated  forty 
times;  thus  each  word  can  be  repeated 
400,000  times,  and  there  are  fifty  words 
on  a  cylinder.  A  sixty-cell  current  is 
at  first  needed  for  the  worst  cases.  At 
the  end  of  a  few  months  one  cell  will 
complete  the  process  where  a  cure  is 
being  effected.  The  number  of  cells  used 
makes  the  instrument  an  audimeter 
which  measures  the  degree  of  deafness. 
On  the  principle  of  Urbantschisch  and 
Gelle,  who  claim  that  many  deaf  ears 
need  only  education  to  give  them  a  cer- 
tain amount  of  hearing  power,  this  ap- 
paratus should  be  of  signal  service  in 
the  teaching  of  deaf-mutes.  Laborde 
(Practitioner,  Apr.,  '98). 

The  above  remarks  on  the  treatment 
of  deaf-mutism  have  exclusively  dealt 
■with  the  deafness  from  which  the  mutism 
results.  I  will  not  go  further  into  the 
treatment  of  mutism  by  special  methods 
of  instruction,  because  this  subject  is  not 
included  in  the  aim  of  this  article,  which 
is  prepared  for  those  who  are  to  give 
their  attention  to  the  diseases  involved. 

It  will  then  be  seen  that  when  a  child 
is  proved  to  have  such  deficient  power  of 
hearing  that  mutism  is  the  result,  re- 
moval of  that  deaf-mutism  by  treatment 
can  only  be  hoped  for  in  very  exceptional 
cases.  Therefore,  there  is  still  greater 
reason  for  considering  the  question  of  the 
prevention  of  deaf-mutism.  The  prin- 
ciple method  of  obtaining  this  object 
must  be  to  submit  all  children  who  suffer 
from  deafness  which  threatens  to  cause, 
or  has  caused,  deaf-mutism  to  a  rational 
examination  of  the  ears  and  of  the  ad- 
jacent mucous  membranes,  and  eventu- 


DERMATITIS. 

ally  to  make  the  existing  disease  the  sub- 
ject of  rational  treatment. 

HOLGER   MyGIND, 

Copenhagen. 

DELIRIUM  TREMENS.     See  Alco- 
holism, Acute  Alcoholic  Delirium. 

DEMENTIA.    See  Insanity. 

DENGUE.     See  Specific  iNFECTioua 
Fetees. 

DERMATITIS. 

Definition. — Inflammation  of  the  skin. 
Varieties.- — -There  are  seven  varieties 
of  dermatitis:  dermatitis  traumatica, 
due  to  traumatic  irritation  of  the  derma; 
dermatitis  venenata,  due  to  contact  with 
poisonous  agents;  dermatitis  medica- 
mentosa; dermatitis  herpetiformis;  der- 
matitis gangrenosa;  dermatitis  maligna; 
and  dermatitis  exfoliativa. 
Dermatitis  Traumatica. 
Under  this  heading  are  included  such 
superficial  inflammations  of  the  skin  as 
follow  pressure,  violence,  contusions, 
abrasions  from  scratching  or  rubbing,  or 
the  action  of  mechanical  irritants  of  any 
kind. 

Case  of  dermatitis  from  Roentgen  rays 
in  a  boy  aged  16.  On  October  13th,  to 
radiograph  the  spine,  a  Crookes  tube  was 
placed  about  5  inches  from  the  epigas- 
trium, a  flannelette  shirt  intervening 
between  the  tube  and  the  skin,  while  the 
trousers  were  turned  down  on  each  aide. 
An  exposure  of  one  hour  was  made,  the 
the  coil  being  run  by  means  of  an  accu- 
mulator. The  next  day  the  akin  felt 
irritable  and  was  of  a  deep-red  color  in 
the  area  subjected  to  the  rays.  The 
irritability  increased,  and,  six  days  after 
the  experiment,  the  skin  felt  stiff  when 
he  bent  his  body.  Vesicles  began  to 
form,  and  they  inereaaed  in  size  and 
number.  The  general  surface  was  of  a 
dusky  or  purplish  red,  forming  an  ir- 
regular band  three-quarters  of  an  inch 
wide  round  the  umbilicus.  On  October 
31st  the  whole  of  the  epidermis  had  sep- 


DERMATITIS  TRAUMATICA.    TREATMENT. 


406 


arated,  and  the  skin  was  quite  sound  and 
level  with  the  surrounding  skin,  except 
where  the  vesioulation  had  been  most 
pronounced.  The  downy  hairs  with 
which  the  abdomen  was  rather  thickly 
covered  were  still  present  on  the  site  of 
the  affected  area.  H.  Radcliffe  Crocker 
(Brit.  Med.  Jour.,  Jan.  2,  '97). 

The  inflammation  of  the  skin  some- 
times noticed  in  connection  with  fluoro- 
scopic or  sciagraphic  observations  is  due 
to  the  absorption  of  radiant  energy  by 
the  cells  of  the  skin,  and  comparable  to 
the  changes  effected  in  the  photographic 
emulsion.  Dermatitis  appears  more  likely 
to  ensue  from  exposure  to  low  than  to 
high  vacuum-tube,  the  vast  majority  of 
rays  with  the  former  being  unquestion- 
ably absorbed  by  the  skin,  while  with 
the  latter  but  few  are  absorbed.  Jones 
(Jour.  Amer.  Med.  Assoc,  Nov.  6,  '97). 

While  the  condition  and  position  of 
the  tube  and  the  time  of  exposure  are 
the  essential  features  in  x-ray  treat- 
ment, yet,  with  every  ordinary  precau- 
tion, cases  are  sometimes  met  with 
which  defy  them  all,  and  with  hardly  a 
note  of  warning  a  violent  dermatitis 
suddenly  breaks  forth.  Case  observed 
which  can  only  be  explained  by  the 
combination  of  personal  idiosyncrasy 
and  cumulative  action  of  the  x-rays. 
Another  case  referred  to  in  which,  even 
when  no  appreciable  dermatitis  was  evi- 
dent, the  slightest  e.xposure  caused 
.  most  unpleasant  sensations  of  burning 
and  itching.  It  was  afterward  learned 
that  the  patient  was  markedly  suscep- 
tible to  the  influence  of  the  poisonous 
ivy.  Idiosyncrasy  is  not  a  negligible 
quantity  in  x-ray  therapeutics,  and  sug- 
gests intervals  of  some  days  between 
each  of  the  first  six  sittings.  A.  D. 
Rockwell  (Medical  Record,  Jan.  10, 
1904). 

The  inflammatory  action  is  usually 
simple,  unless  the  tissues  become  in- 
fected by  staphylococci  or  streptococci, 
when  pus-formation  or  erysipelatous  in- 
flammation may  follow.  A  common 
form  of  simple  dermatitis  is  that  result- 
ing from  chafing;  while  this,  under  the 
name  intertrigo,  is  usually  classed  among 


the  congestive  erythemas,  it  more  fre- 
quently runs  into  true  inflammation. 

The  most  frequent  sites  for  the  in- 
tertriginous  dermatitis  are  the  armpits, 
perineum,  and  insides  of  the  thighs  and 
the  under-surfaces  of  pendulous  breasts, 
especially  in  corpulent  women.  It  is 
more  frequent  in  summer  than  in  win- 
ter, as  free  perspiration,  macerating  the 
upper  layers  of  the  skin,  and  undergoing 
decomposition,  with  the  formation  of 
irritant  compounds,  promotes  the  oc- 
currence of  the  inflammation. 

Intertriginous  dermatitis  is  very  fre- 
quent in  infants  and  young  children, 
especially  if  great  care  is  not  taken  to 
keep  the  genital  and  anal  regions  clean 
and  dry.  The  most  aggravated  derma- 
titis of  the  genitals,  insides  of  the  thighs, 
and  lower  part  of  the  belly  may  develop 
in  a  few  hours  in  an  infant  allowed  to 
lie  in  a  wet  and  dirty  napkin.  The  pain, 
itching,  and  burning  are  sometimes  very 
intense,  preventing  sleep  and  keeping 
the  child  in  a  state  of  high,  nervous 
tension,  crj'ing  and  irritable. 

Treatment. — In  simple  traumatic  der- 
matitis any  soothing  application  will  be 
useful.  Cold  cream,  oxide-of-zinc  oint- 
ment, or  simple  vaselin  are  usually  suffi- 
cient to  allay  the  inflammation.  One  of 
the  best  applications  is  hot  water,  ap- 
plied for  five  or  ten  minutes  several 
times  a  day.  The  water  should  not  be 
merely  warm,  but  as  hot  as  can  be  borne 
without  discomfort. 

For  intertriginous  dermatitis  the 
writer  has  found  black-wash  the  best 
application.  Applied  on  lint  saturated 
with  the  preparation,  it  usually  gives 
prompt  relief  from  the  burning  and 
pain  and  controls  the  hypera?mia.  A 
mild  calomel  ointment,  V;  drachm  to 
the  ounce  of  vaselin  is  also  useful.  In 
other  cases  Ivassar's  paste  is  useful. 
This  is  made  as  follows; — 


4:06 


DERMATITIS  VENENATA.    DEFINITION. 


^  Acidi  salicylici,  gr.  s. 
Pulv.  amyli, 

Zinci  oxidi,  of  each,  oij. 
Taselin,  §ss. 
M.  ft.  pasta. 

Great  care  should  be  taken  that  only 
the  finest  powdered  salicylic  acid  be 
used  in  making  this  and  other  ointments 
containing  it.  The  crystallized  acid  usu- 
ally proves  extremely  irritating  to  an 
inflamed  or  sensitive  skin. 

For  the  moderate  grades  of  intertrigo 
or  chafing,  a  simple  dusting-powder  of 
starch  and  oxide  of  zinc  is  generally 
sufficient,  if  the  irritated  skin  be  kept 
clean  and  dry.  The  interposition  of  a 
fold  of  lint  or  soft  linen  between  oppos- 
ing surfaces  of  skin  is  an  aid  to  the 
cure  as  well  as  the  prevention  of  inter- 
triginous  dermatitis. 
Dermatitis  Venenata. 
Definition. — Inflammation  of  the  skin 
produced  by  external  irritating  agents 
derived  from  the  vegetable,  mineral,  or 
animal  kingdoms. 

Records  of  some  unrecognized  forms  of 
dermatitis  venenata.  Thus,  a  papulo- 
vesicular eruption,  accompanied  by  much 
heat  and  itching,  may  attack  the  hands 
and  arms  of  persons  employed  in  weed- 
ing parsnips,  or  in  otherwise  handling 
them.  The  upper  part  of  the  body  of  a 
man  who  had  applied  to  his  shoulder, 
on  account  of  rheumatism,  a  mixture  of 
hamamelis  and  laudanum,  became  cov- 
ered with  large  vesicles,  papules,  and 
oozing  areas.  Here,  no  doubt,  an  idio- 
syncrasy to  opium  may  have  existed. 
The  hands  of  a  gii-1  employed  in  dipping 
wooden  toothpicks  in  oil  of  cassia,  to 
give  these  an  agreeable  odor,  were,  in  a 
few  days  after  she  commenced  this  oc- 
cupation, inflamed,  and  covered  with 
vesicles  and  moist  areas;  her  face  was 
red  and  blotchy,  and  the  lower  portion 
of  the  abdomen  was  similarly  afTcctcd, 
probably  from  contact  during  sleep.  A 
number  of  firemen,  to  whom  new  black 
cotton  shirts  had  been  issued  as  part  of 
their  summer  uniform,  became  aflccted 


with  a  brilliant-red  infiltrated  erythema 
on  those  portions  of  their  body  where 
the  sliirt  came  in  contact.  Solar  heat 
and  consequent  perspiration  seemed  to 
have  brought  out  the  activity  of  the 
dye.  Analysis  proved  the  pigment  an 
aniline  one.  James  C.  White  (Boston 
Med.  and  Surg.  Jour.,  Jan.  28,  '97). 

Outbreak  of  34  cases  of  acute  derma- 
titis among  a  number  of  workmen  who 
had  just  been  provided  with  new  over- 
coats. On  first  wet  day  following  the 
wearing  of  coats  inflammation  of  the 
skin  began  to  manifest  itself  on  the  back 
of  the  wrists,  the  only  point  at  which 
the  coat  came  in  contact  with  the  skin. 

The  patches  were  sliglitly  depressed 
and  had  the  appearance  of  a  necrosis  of 
the  epidermis  such  as  follows  the  appli- 
cation of  a  strong  irritant.  Tactile  sen- 
sation was  entirely  lost  in  the  afl'ected 
areas,  and  the  appearances  were  most 
marked  in  the  neighborhood  of  existing 
abrasions.  In  three  cases  there  was 
some  inflammation  of  the  arm,  with  en- 
largement of  the  axillary  glands.  In- 
fusion of  the  cloth  from  which  the  over- 
coats were  made  yielded  an  acid  reac- 
tion, and  was  found  to  contain  zine 
chloride,  which  caused  the  skin  condi- 
tion.    Taunton   (Lancet,  Dec.  6,  '98). 

There  are  many  common  plants  that 
will  cause  dermatitis,  idiosyncrasy,  how- 
ever, playing  an  important  part.  The 
common  plants  are  those  of  the  rhus 
group  —  the  poison-ivy,  dogwood  or 
poison-sumach,  and  the  poison-oak. 
Japanese  lacquer  may  cause  it  even  in 
handling  pictures.  Among  the  ordinary 
wild  flowers  are  the  butter-cup,  fleld- 
daisy,  golden-rod,  wood-anemone,  clema- 
tis, and  garden-nasturtium.  Among  the 
drugs  used  in  applications,  dermatitis 
may  be  caused  by  tincture  of  arnica, 
balm  of  Gilead,  hamamelis,  common  salt 
in  strong  solution,  belladonna,  and  many 
proprietary  remedies  containing  the  es- 
sential oils.  Kerosene  may  cause  an 
eruption.  Glycerin,  almond-oil,  iodoform, 
carbolic  acid,  salicylic  acid,  quinine,  sul- 
phur, tar,  and  chrysarobin  occasionally 
cause  inflammation.  Among  substances 
brought  into  contact  with  the  skin  on 
account  of  occupation,  and  which  may 
cause  a  dermatitis,  are  strong  alkalies, 


DERMATITIS  VENENATA.    VARIETIES. 


4or 


Boaps,  "pearline,"  "soapine,"  metal  and 
shoe  polishes,  paint-pigments,  arsenic, 
potassium  bichromate,  the  various  salts 
of  mercury  and  even  the  metal,  and 
cliocolate.  Animal  irritants  are  the  mos- 
quito, Ilea,  bed-bug,  black  fly,  wasp,  bee, 
hornet,  spider,  caterpillar,  and  jelly-fish. 
G.  F.  Harding  (Boston  Med.  and  Surg. 
Jour.,  Sept.  G,   1900). 

Varieties.  —  (A)  Dekmatitis  From 
Vegetable  Irritants. — A  large  num- 
ber of  plants,  some  of  them  used  medic- 
inally, possess  irritant  properties  when 
brought  in  contact  with  the  skin. 

Fhus,  or  Poison-ivy.  —  Among  the 
above  the  most  important  are  various 
species  of  rhus ;  namely  BMis  toxicoden- 
dron, or  poison-ivy;  Bhus  venenata,  or 
poison-sumach;  and  Rhus  diversiloia,  or 
poison-oak.  The  latter,  according  to 
J.  C.  White,  is  a  native  of  the  Pacific 
coast,  although  the  common  R.  tox- 
icodendron is  also  vulgarly  known  as 
poison-oak. 

When  a  person,  susceptible  to  the 
poison  of  one  of  these  species  of  rhus, 
touches  the  plant,  or,  in  some  cases,  even 
comes  within  a  short  distance  of  the 
same,  the  skin  shows  signs  of  irritation 
manifested  as  follows:  There  may  be 
redness,  but  more  frequently  the  first 
objective  sign  is  the  eruption  of  groups 
of  small  vesicles,  accompanied  by  swell- 
ing and  intense  itching.  In  consequence 
of  the  scratching  set  up,  the  vesicles  are 
ruptured  and  exude  an  abundant  serum. 
The  swelling  is  sometimes  very  great, 
especially  about  the  loose  tissues  of  the 
face  and  the  genital  regions.  The 
eruptions  usually  begin  upon  the  hands, 
as  these  are  the  parts  of  the  body  most 
frequently  brought  in  contact  with  the 
poison.  From  the  hands  it  is  generally 
transferred  to  the  face,  and  next,  in  the 
male  sex  especially,  to  the  genitals,  be- 
cause the  face  and  genitals  are  the  parts 
most  frequently  handled.    The  face  and 


head  are  often  so  intensely  swelled  as  to 

be  almost  unrecognizable. 

Death  from  ivy  poisoning  in  a  man 
42  years  old  after  two  montlis  of  in- 
tense suffering.  Some  persons  are  af- 
fected by  merely  passing  the  plant  with- 
out coming  in  contact  at  all,  while 
otliers  can  -handle  it  with  impunity. 
Case  observed  in  a  child  6  years  old 
who  died  from  tlie  effects  of  severe  ivy 
poisoning  produced  by  having  his  skin 
rubbed  wliile  wet  by  tlie  hands  of  a  boy 
who  had  been  rooting  up  plants  of  the 
poison  ivy,  and  although  the  boy  had 
previously  washed  his  hands  thor- 
oughly, under  supervision,  first  with 
soap  and  hot  water,  and  afterward  with 
vinegar.  The  boy  who  had  been  work- 
ing with  the  plants  had  a  full  and  ap- 
parently permanent  Immunity  to  poi- 
son ivy.  Reynolds  (Bull,  of  Chicago 
Health  Dept.,"  July  2.3,  1904). 

Sometimes  the  skin  is  very  much 
reddened  and  the  exudation  abundant. 
Excoriated  patches  are  frequent.  The 
itching  varies  from  mild  grades  to  the 
most  severe  intensity,  but  is  generally  a 
prominent  symptom.  It  is  said  that 
death  has  followed  the  poison,  but  the 
testimony  upon  this  point  is  rather 
vague. 

The  common  belief  that  an  eruption 
caused  by  rhus  poisoning  is  liable  to 
recur  annually  without  renewed  exposure 
is  not  based  upon  sufficiently-definite 
evidence.  The  fact  that  the  dermatitis 
recurs  at  about  the  same  time  each  year 
is  to  be  attributed  to  a  new  exposure. 
'WTiite,  however,  mentions  a  number  of 
cases  in  which  a  different  eruption  fol- 
lowed— after  an  interval — the  attack  of 
rhus  poisoning. 

The  chemical  nature  of  the  poison  of 
the  various  species  of  rhtis  is  somewhat 
obscure,  but  a  number  of  researches  in- 
dicate that  it  is  a  volatile  acid.  A  num- 
ber of  cases  are  on  record  showing  that 
handling  dried  specimens  of  the  poison- 
ous plants  may   produce  an   eruption. 


408 


DERMATITIS  VENENATA.     TREATMENT. 


The  time  after  exposure  when  the  erup- 
tion appears  differs  in  different  persons. 
The  shortest  is,  perhaps,  four  or  five 
hoirrs,  while  in  some  eases  it  may  be  as 
many  days  before  the  effects  of  the  poi- 
son on  the  skin  are  manifested.  That 
the  poison  before  volatilization  may  be 
transferred  from  one  portion  of  the  body 
to  another — as  from  the  hands  to  the 
face  or  to  the  genitals — is  beyond  ques- 
tion. 

Case  of  dermatitis  venenata  conveyed 
to  a  patient  in  the  obstetrical  ward  of  a 
hospital  by  the  attendants,  who  had, 
just  before  the  patient's  delivery,  gath- 
ered a  quantity  of  poison-ivy,  and  then, 
although  having  previously  carefully 
washed  their  hands,  had  manipulated  the 
patient's  abdomen.  J.  Abbott  Cantrell 
(Med.  News,  Oct.  24,  '91). 

It  has  been  hitherto  accepted  that  the 
toxicodendric  acid  described  by  Maisch 
was  the  active  principle  of  rhus  poison- 
ing, but  found  to  be  merely  acetic  acid. 
A  poisonous  oil,  however,  termed  "toxi- 
codendrol,"  is  the  toxic  element, — a  very 
intense  skin  irritant,  even  in  minute 
quantity.  Like  cantharides,  it  can  pro- 
duce nephritis  and  fatty  degeneration  of 
the  kidneys,  and  it  is  probable  that 
fatal  results  of  rhus  poisoning  may  have 
been  due  to  renal  complications.  It  is 
non-volatile;  actual  contact  appears 
necessary.  The  activity  of  toxicodendrol 
in  minutest  traces  may  make  it  possible 
for  a  few  pollen  grains  of  poison-ivy  to 
cause  skin  eruption;  and  the  few  cases 
of  action  at  a  distance,  which  are  so 
often  quoted,  may  conceivably  be  thus 
explained. 

The  rational  indication  is  to  get  rid  of 
the  poisonous  oil  which  may  be  on  the 
skin  as  quickly  as  possible;  the  parts 
should  be  well  washed,  and  scrubbed 
with  soap  and  water,  or  alcohol.  Fatty 
preparations,  being  oil  solvents,  if  used, 
tend  but  to  spread  the  evil.  PfafT  (Jour. 
Exp.  Med.,  Mar.,  '97). 

Poisoning  from  the  action  of  the  Rhus 
toxicodendron  is  differentiated  from  ec- 
zema by  the  vesicles  being  much  more 
numerous,    swelling    and    oedema    being 


greater,  and  exposed  parts  being  more 
likely  to  be  afl'ected,  particularly  the 
inner  surfaces  of  the  fingers,  while  the 
eczematous  eruption  is  more  frequently 
polymorphous.  Sun-burn  sometimes  re- 
sembles dermatitis  venenata,  but  it  is 
more  diffuse,  and  is  usually  localized  en- 
tirely to  exposed  parts,  while  rhus 
poisoning  alfeets  the  breasts  and  geni- 
talia also.  Scabies  is  excluded  by  the 
history  and  by  the  absence  of  the 
Acarus  scabiei.  3.  Sobel  (Med.  Rec, 
Nov.  5,  '98). 

Blastomycetie  dermatitis  is  due  solely 
to  the  invasion  of  the  skin  by  one  of  the 
plant  forms  of  the  yeast  family.  In  its 
clinical  aspect  it  resembles  lupus  vul- 
garis in  the  ulcerative  stage.  Hyde, 
Hektoen,  and  Bevan  (Brit.  Jour,  of 
Derm.,  July,  '99). 

Treatment. — The  most  effective  ap- 
plications in  the  early  stages  of  rhus 
poisoning  are  alkaline  solutions,  soap 
being  especially  useful  on  account  of  its 
detergent  effect.  By  its  early  use,  the 
greater  portion  of  the  poison  can  be 
removed,  or  its  effects  neutralized,  be- 
fore it  has  had  time  to  penetrate  the 
skin  and  act  as  an  irritant.  Solutions 
of  bicarbonate  of  soda,  1  ounce  to  the 
pint,  and  black-wash  usually  relieve  the 
itching  promptly.  Hardaway,  of  St. 
Louis,  recommends  very  highly  a  lotion 
of  zinc  sulphate,  ^/j  drachm  to  the 
pint  of  water.  Fluid  extract  of  grin- 
delia  robusta,  either  full  strength  or 
diluted  with  water  in  various  propor- 
tions, is  highly  lauded  by  Van  Har- 
lingen  and  others.  When  the  vesicles 
have  ruptured,  drying  or  absorbent  pow- 
ders of  starch,  chalk,  oxide  of  zinc,  orris- 
root,  lycopodium,  etc.,  may  be  used  with 
good  effect.  Astringent  lotions,  among 
which  acetate  of  lead  holds  a  high  place, 
are  especially  useful  when  the  eruption 
is  fully  developed. 

James  C.  White,  of  Boston,  recom- 
mends the  following  prescription: — 


DERMATITIS  VENENATA.     TREATMENT. 


409 


I^   Zinci  oxidi,  oiv. 
Acidi  carbolici,  oj. 
Aquse  calcis,  Oj. — M. 

This  should  be  applied  freely  and  re- 
peatedly over  the  affected  parts.  It 
alleviates  the  intense  itching  and  hastens 
the  involution  of  the  inflammatory  proc- 
ess. Internal  remedies  are  unnecessary 
and  useless. 

In  the  treatment  of  dermatitis  ven- 
enata, good  results  obtained  with  a  modi- 
fied "Cunow  solution,"  containing  1 
drachm  of  lead  acetate  and  3  drachms  of 
alum  to  a  quart  of  water.  Picric  acid, 
in  a  1-per-cent.  solution,  is  also  useful. 
Salol  in  a  3-per-cent.  solution  is  espe- 
cially good.  J.  Sohel  (Med.  Eec,  Nov. 
5,  '98). 

Remedy  for  dermatitis  venenata  upon 
which  most  reliance  is  personally  placed 
is  sodium  hyposulphite,  in  the  strength 
of  Vj  ounce  to  2  ounces  dissolved  in  a 
pint  of  water.  The  affected  part  is 
mopped  freely  and  frequently,  or 
wrapped  up  in  a  cloth  or  bandage  satu- 
rated with  the  fluid,  which  is  renewed 
as  soon  as  the  dressing  has  become  dry. 
E.  S.  Gans  (Med.  Bull.,  Aug.,  '99). 

Dermatitis  venenata  successfully 
treated  by  using  locally  a  lOper-cent. 
solution  of  ichthyol  and  a  1  to  5000  so- 
lution of  mercury  bichloride;  internally, 
a  calomel  purge  followed  by  capsules  of 
quinine,  guaiacol  carbonate,  and  phenace- 
tin  every  four  hours.  J.  A.  Colnane 
(No.  Anier.  Jour,  of  Diag.  and  Pract., 
iii,  4,  p.  13,  1900). 

Arnica  and  Other  Toxic  Agents. — The 
tincture  of  arnica  is  so  freely  used  as 
an  external  application  to  bruises  and 
sprains  that  it  may  be  useful  to  the 
practitioner  to  know  that  it  sometimes 
produces  a  decided  dermatitis,  which 
may  be  accompanied  by  vesiculation. 
The  cessation  of  the  application,  and 
dressing  the  affected  part  with  a  sooth- 
ing or  mildly-astringent  lotion  (bicar- 
bonate of  soda,  borax,  sulphate  of  zinc) 
will  generally  suffice  to  restore  the  nor- 
mal condition  of  the  part. 


Among  other  agents  used  for  medic- 
inal purposes,  which  produce  dermati- 
tis of  varying  intensity,  are  mustard, 
cowhage,  chrj'sarobin,  ipecac,  capsicum, 
mezereuni,  thapsia,  cantharides,  oil  of 
turpentine,  tar,  creasote,  paraffin,  petro- 
leum, pyrogallic  and  salicylic  acids,  chlo- 
ral-hydrate, sulphur,  iodine,  mercurial 
preparations,  and  the  more  active  alka- 
line, acid,  and  mineral  caustics. 

The  knowledge  may  also  be  useful 
that  the  juice  of  the  common  buttercup 
of  the  fields  and  the  garden  nasturtium 
may  cause  inflammation  of  the  skin. 

Dermatitis  caused  on  four  occasions 
by  using  iodoform  in  as  many  patients 
operated  on.  In  tlie  second  instance  the 
hand  also  had  accidentally  come  into 
contact  with  the  iodoform;  this  lead 
to  dermatitis  of  the  area  thus  exposed. 
On  the  two  latter  occasions  the  derma- 
titis was  accompanied  by  erysipelas, 
and  led  to  prolonged  pigmentation.  This 
shows  that  no  breach  in  the  skin  is  re- 
quired to  produce  this  inflammation. 
Matschke  (Ther.  Monats.,  Oct.,  '93). 

Case  showing  untoward  effect  of  re- 
sorcin  applications:  a  single  application 
sufficient  to  set  up  a  violent  dermatitis. 
R.  W.  Taylor  (Jour,  of  Cut.  and  Uenito- 
Urin.  Dis.,  Apr.,  '95). 

[These  artificial  eruptions  provoked 
by  resorcin  are  relatively  frequent,  and 
this  substance  should  only  be  used  with 
much  precaution,  beginning  with  almost 
infinitesimal  doses  and  suspending  its 
use  at  the  slightest  sign  of  irritation.  L. 
Brocq,  Assoc.  Ed.,  Annual,  '96.] 

(B)  Dermatitis  from  Animal  Irri- 
tants.— Among  cases  of  dermatitis  ven- 
enata of  animal  origin  may  be  included 
the  cutaneous  inflammations  caused  by 
the  stings  and  bites  of  insects,  such  as 
bees,  wasps,  fleas,  bed-bugs,  lice,  and 
mosquitoes.  The  inflammatory  effects 
vary  in  different  persons.  While  in  most 
cases  the  bite  of  a  mosquito  will  produce 
simply  a  small,  itching  papule,  in  others, 
large  red,  painful  lumps  are  raised,  which 


410 


dek:matitis  medicamentosa,   definition,   varieties. 


give  rise  to  great  discomfort  and  often 
alarm.  The  treatment  is  purely  symp- 
tomatic. Alkaline  lotions  are  generally 
most  effective.  [See  Wounds,  Poisoned. 
Ed.] 

Dermatitis  Medicamentosa. 

Definition. — Inflammation  of  the  skin 
caused  by  the  action  of  medicinal  agents 
taken  into  the  sj'stem. 

Very  many  medicines  when  adminis- 
tered for  therapeutic  purposes  pro- 
duce, among  other  by-effects,  inflamma- 
tion of  the  skin.  This  may  find  ex- 
pression in  erythematous,  papular,  vesic- 
ular, bullous,  tubercular,  or  ulcerative 
lesions.  No  distinctive  diagnostic  marks 
can  be  given  for  these  eruptions,  but  the 
occurrence  of  any  eruption,  not  readily 
explained  by  other  causes,  should  lead 
to  an  inquiry  concerning  the  possible 
effect  of  medicines  ingested.  Thus,  an 
eruption  almost  identical  in  appearance 
with  that  of  scarlet  fever  at  times  fol- 
lows the  administration  of  quinine. 

In  the  quinine  eruption  the  high 
fever  and  sore  throat  of  scarlatina  are 
absent.  A  bullous  eruption,  resembling 
pemphigus,  may  follow  the  ingestion  of 
iodide  of  potassium,  which  drug  may  also 
produce  tubercular,  pustular,  and  ulcer- 
ative lesions.  A  papulo-erythematous 
eruption,  suggestive  of  measles,  occa- 
sionally follows  antipyrine.  Copaiba 
may  cause  a  macular  eruption  resem- 
bling the  erythematous  syphilide.  The 
scarlatiniform  rash  of  belladonna  is  well 
known.  In  some  susceptible  subjects 
opium  preparations,  in  addition  to  itch- 
ing, may  also  give  rise  to  an  urticarial  or 
erythematous  eruption. 

Varieties  of  Eruption  Observed 
AFTER  Ingestion  of  Different  Drugs. 
— Erythematous  and  erythemato-papu- 
lar  eruptions  are  sometimes  observed 
after  taking  belladonna,  hyoscyamus, 
stramonium,    quinine,    nitrite    of   amyl, 


chloroform,  arsenic,  opium,  turpentine, 
cubebs,  copaiba,  antipyrine,  and  ben- 
zoate  of  sodium.  Sometimes  these  are 
attended  with  more  or  less  severe  itch- 
ing, and  may  resemble  urticaria.  (See 
various  remedies  in  which  these  mani- 
festations occur.) 

Case  of  dermatitis  medicamentosa  dif- 
fusa following  upon  a  dose  of  opium. 
The  whole  skin  became  red  and  covered 
with  large  scales.  The  skin  was  dry. 
jMovements  were  interfered  with  on  ac- 
count of  the  pain  in  the  skin.  The  epi- 
dermis was  shed  in  large  plates  so  as 
to  form  complete  casts  of  the  hands  and 
feet.  The  normal  lines  of  the  skin  were 
accentuated.  The  mucous  membrane  of 
the  mouth  was  dry  and  red.  The  patient 
complained  of  tenseness  of  the  skin, 
chilliness,  thirst,  loss  of  appetite,  head- 
ache, and  insomnia.  Lanz  (Monats.  f. 
Prakt.  Derm.,  No.  309,  '93). 

Mixed  erythematous  rashes  (polymor- 
phous erythema)  have  occurred  after  the 
administration  of  arsenic,  quinine,  digi- 
talis, copaiba,  and  bromide  of  potassium. 

Vesicular  and  bullous  eruption  may 
follow  arsenic  (herpes  zoster),  cannabis 
Indica,  iodide  and  bromide  of  potassium, 
quinine,  salicylate  of  sodium,  and  phos- 
phoric acid. 

Pustular  and  phlegmonous  eruptions 
(pustules,  boils,  abscesses,  diffuse  phleg- 
monous or  erysipelatous  inflammation) 
have  been  noted  after  taking  iodide  and 
bromide  of  potassium,  arsenic,  quinine, 
hyoscyamus,  opium,  chloral-hydrate, 
digitalis,  iodide  of  mercury,  calomel,  and 
pilocarpine. 

Superficial  ulcerations  about  the  roots 
of  the  nails  sometimes  follow  the  pro- 
longed administration  of  chloral-hydrate. 

Purpuric  extravasations  have  been 
noted  after  iodide  of  potassium,  salicylic 
acid,  quinine,  chloral-hydrate,  and  cam- 
phor. 

Treatment. — The  treatment  of  drug 
eruptions  must  be  symptomatic.     The 


DERMATITIS  HERPETIFORMIS.     DEFINITION.     SYMPTOMS. 


411 


administration  of  the  remedy  must  be 
stopped,  and  other  indications  met  as 
they  arise. 

Dermatitis  Herpetiformis. 

Definition. — An  inflammatory,  super- 
ficially-seated, multiform,  herpetiform 
eruption,  characterized  mainly  by  ery- 
thematous, vesicular,  pustular,  and  bull- 
ous lesions,  occurring  usually  in  varied 
combinations,  accompanied  by  burning 
and  itching,  pursuing  usually  a  chronic 
course  with  a  tendency  to  relapse  and 
recur.     (L.  A.  Duhring.) 

The  acute  observations  and  logical 
reasoning  of  Duhring  with  reference  to 
this  disease  have  led  to  a  general  ac- 
ceptance of  his  views  on  the  part  of 
dermatologists.  At  one  time  Duhring 
classed  the  disease  first  described  by 
Hebra  under  the  name  of  "impetigo 
herpetiformis,"  as  the  pustular  variety 
of  D.  herpetiformis,  but  in  his  latest 
publication  ("Cutaneous  Medicine,"  Part 
II)  he  regards  it  as  advisable  to  consider 
the  two  diseases  as  distinct  "from  a  clin- 
ical stand-point,  at  least."  Uima  and 
Stephen  Mackenzie  lay  stress  upon  the 
neurotic  origin  of  D.  herpetiformis. 

Symptoms. — Duhring,  upon  whose  ex- 
haustive studies  the  following  descrip- 
tion is  based,  recognizes  five  varieties  of 
the  disease,  namely:  the  erythematous, 
vesicular,  bullous,  pustular,  and  multi- 
form, indicating  the  prevailing  type  of 
lesion  present. 

There  is  usually  a  prodromic  febrile 
stage,  which,  however,  rarely  amounts  to 
more  than  slight  chilliness,  flushing,  or 
heat,  ^Y\th  the  accompaniments  of  ma- 
laise and  constipation.  Itching  may  pre- 
cede the  outbreak  of  the  eruption.  Any 
one  variety  of  lesion  may  appear,  or 
there  may  be  from  the  beginning  a  com- 
bination of  two  or  more  of  them.  The 
type  of  lesion  may  change  during  the 
course  of  the  disease,  or,  as  is  more  rare. 


may  remain  constant  throughout  the  at- 
tack, and  may  also  show  the  same  feat- 
ures in  subsequent  attacks.  The  sub- 
jective sensations  are  burning,  itching, 
and  prickling,  which  may  be  severe.  In 
one  case  of  the  vesiculo-pustular  variety, 
the  itching  and  burning  were  most  in- 
tense, relief  being  obtained  only  after 
the  application  of  strong  ointments  or 
lotions  of  cocaine. 

The  erytliematous  variety  occurs  in 
patches  or  diffused  over  the  surface. 
There  is  usually  slight  elevation  of  the 
afl^ected  skin.  The  red  color  of  the  erup- 
tion may  be  varied  by  a  yellowish  or 
brownish  tint,  and  is  usually  followed 
by  more  or  less  pigmentation. 

The  vesicular  variety  is  the  most  com- 
mon. The  vesicles  are  irregular  in  size 
and  shape,  usually  tense,  and  rising 
abruptly  from  an  apparently  normal 
base.  They  may  be  disseminated  or  ag- 
gregated in  groups  or  clusters.  They 
sometimes  coalesce  to  form  small  blebs. 
The  itching  is  usually  more  intense  than 
in  other  forms  of  eruption.  After  the 
vesicles  rupture  there  is  often  some  relief 
from  this  symptom.  Excoriation  is  usu- 
ally not  very  marked. 

In  the  bullous  variety  the  bullae  are 
usually  tense,  standing  out  from  the 
level  of  the  skin.  They  are  usually  ir- 
regular in  outline,  differing  from  the 
bullre  of  pemphigus.  They  are  also  more 
likely  to  appear  in  groups  or  clusters. 
Vesicles  and  pustules  may  accompany 
the  blebs. 

Case  of  recurrent  bullous  dermatitis 
in  a  woman  23  years  of  age,  who  wa8 
distinctively  hysterical  and  of  a  tiiber- 
culous  parcntafre.  During  the  past 
three  years  she  had  sulTcred  from  a  re- 
current bullous  dermatitis,  which  had 
attacked  one  part  of  the  body,  each  at- 
tack lasting  about  a  week  and  leaving 
no  mark  behind.  It  is  an  example  of 
an  extraordinary  hysterical  dermatosis. 
It    seemed    impossible    to    regard   these 


412 


DERMATITIS  HERPETIFORMIS.    ETIOLOGY. 


one-sided,    periodical,    progressive    bul- 
lous outbreaks  as  due  to  the  ingestion 
of  drugs  or  to  the  infliction  of  self-in- 
juries, and  the  writer  knew  of  no  cu- 
taneous   disease    with    such    character- 
istics, outside  of  the  mysterious  derma- 
toses which  he  had  learned  to  associate 
with  hysteria.     ^^Tiite  (Medical  Record, 
Sept.  19,  1903). 
The  pustular  form  appears  pustular 
from  the  beginning.     The  lesions  are 
either  acuminate,  discrete,  up  to  a  pea 
in  size,  or  fiat,  not  elevated  above  the 
skin,  aggregated  in  small  groups,  and 
miliary   in   size.     The    larger   pustules 
often  have  a  puckered  appearance. 

The  multiform  variety  is  made  up  of 
all  the  various  types  of  eruption  in  com- 
bination, and  has  suggested  one  of  the 
names  by  which  the  disease  is  known, 
viz.:  dermatitis  multiforme.  The  lesions 
are  macules,  papules,  vesicles,  pustules, 
and  bullae  of  all  shapes  and  sizes.  There 
are  excoriations  and  pigmentations  of  a 
brownish  color.  The  character  of  the 
lesions  is  constantly  changing. 

Dermatitis  Herpetiformis.  —  The 
course  of  the  disease  is  a  chronic  one, 
and  it  may  last,  appearing  and  disappear- 
ing at  intervals  for  many  years.  Treat- 
ment has  usually  little  effect  upon  its 
progress. 

Two  cases  of  symptomatic  dermatitis 
occurring  in  puerperal  women.  In  the 
first  case  the  eruption  appeared  as  a 
papular  erythema  on  the  fifth  day  post- 
partum, while  in  the  second  it  was  a 
bright-red  flush  on  the  eighth  day  after 
labor.  Wilson  (Annals  of  Gynec.  and 
Ped.,  May,  '91). 

Herpetiform  dermatitis  in  pregnancy 
is  a  rare  disease,  little  known  even  to 
obstetricians.  It  is  distinguished  by  five 
principal  characteristics:  1.  A  poly- 
morphous eruption,  with  a  predominance 
of  bullous  vesicles;  simple  vesicles, 
bullcc,  pustules,  erosions,  crusts,  and 
spots  were  met  with  at  vhe  same  time. 
2.  An  accompanying  pruriginous  disease, 
really  painful.  3.  Good  general  health. 
4.  SuccesHivc  attacks  of  the  disease.     5. 


A  chronic  character,  aggravated  by  each 
attack  of  the  disease,  which  may  last 
for  some  years.  Fournier  (Jour,  de 
Med.  et  de  Chir.  Prat.,  Oct.  10,  '92). 

Four  cases  of  Duhring's  disease  in 
which  glycosuria  was  a  symptom.  Win- 
field  (Jour,  of  Cut.  and  Genito-Urin. 
Dis.,  Nov.,  '93). 

Two  cases  in  two  sisters  living  apart, 
interesting  as  showing  family  tendency, 
liability  to  onset  in  a  predisposed  person 
on  change  of  climate,  and  general  in- 
tractability of  the  complaint.  J.  J. 
Mooney   (Med.  Age,  Aug.  10,  '95). 

Case  of  typical  recui'rent  dermatitis 
herpetiformis,  the  lesions  consisting  of 
a  central  bulla  surrounded  by  an  areola 
of  spreading  centrifugal  erythema.  Be- 
tween this  areola  and  the  collapsed 
original  bulla  a  ring  of  vesicles  fre- 
quently made  their  appearance.  It  is 
uncommon  to  have  the  lesions  of  derma- 
titis herpetiformis  so  closely  simulating 
erythema  multiforme.  John  Liddell 
(Brit.  Jour,  of  Derm.,  p.  385,  '96). 

Etiology.  • — •  It    sometimes   begins   in 
childhood,  but  most  frequently  between 
30  and  40  years  of  age.    There  seems  to 
be  some  connection  between  the  disease 
and  instability  of  the  nervous  system, 
but  nothing  is  definitely  known  upon 
this  point.    There  seems  to  be  a  frequent 
relation  between  the  eruption  and  preg- 
nancy, the  puerperal  state,  or  menstrual 
disturbances.     The  disease  described  by 
Bulkley  and   others   as   "herpes  gesta- 
tionis"  is  probably  a  vesicular  or  vesic- 
ulo-buUous   form    of   D.    herpetiformis 
occurring    during    pregnancy.      There 
seems,   also,   some   connection   between 
renal  defect  and  D.  herpetiformis.     It 
has  been  observed  after  septic  infection. 
Case  of  dermatitis  herpetiformis  in  a 
woman  of  42  with  a  rheumatic  history. 
Slie  sufFercd  in  1895  from  a  stufTed-up 
feeling  in  the  eyes,  nose,  and  throat,  and 
soon    after    blisters    came    out    on    the 
tongue;    a   little   later   on   the   chin;    a 
hot    bath    was    followed    by    a    copious 
eruption    of    vesicles    on    the    face    and 
arms,   which   swelled   greatly,   and   also 
on  the  chest  and  thighs.    Fresh  eruptions 


DERMATITIS  HERPETIFORMIS.    PATHOLOGY.    DIAGNOSIS. 


413 


appeared  consecutively,  with  soreness 
in  the  mouth,  eyes,  and  nose,  and  vio- 
lent paroxysmal  itching  and  burning  of 
the  affected  areas.  The  attacks  con- 
tinued, and  in  November,  1896,  the 
vesicles  were  both  discrete  and  confluent, 
and  also  multilocular.  Considerable 
eosinophilia  of  the  compound-nuclear, 
coarsely-granular  type  were  found  in 
the  blood,  the  eosinophiles  reaching  4.9 
per  cent,  of  all  leucocytes  present. 

Again,  when  the  eruption  was  at  its 
height,  the  eosinophiles  reached  12  per 
cent,  of  all  leucocytes  present  in  four 
specimens.  The  disease  seems  to  exhibit 
the  same  features  of  multiformity,  re- 
currence, and  obstinacy  in  the  natives  of 
India    as    among    white    races.      Morris 


Fig.  1  shows  two  vesicles  (F„  F,) 
which  have  been  formed  entirely  be- 
neath the  epidermis.  Macroscopically 
both  vesicles  were  about  the  size  of  a 
small  pin-head.  The  entire  upper  half 
of  the  corium  is  the  seat  of  acute  inflam- 
mation. S  is  a  sweat-duct;  B  indicates 
small  blood-vessels,  and  G  is  a  sebaceoua 


Fig.  2  shows  the  stage  preceding  the 
formation  of  the  vesicles.  Large  num- 
bers of  eosinophiles  (E)  are  to  be  seen 
scattered  throughout  the  papillae. 

Fig.  3  shows  the  first  stage  in  the 
formation    of    the    vesicles.      Immense 


■- '  ^^•aWBf'^i 

^¥^22 

1 

■rr  '"'^mi^'S^'^M 

.y^''^"-    ^ 

-  x-J-f^\-^)J^'\-- 

Dermatitis  herpetiformis.      (Liddcll.) 


and    Whitfield     {Brit.    Jour,    of    Derm., 
June,  '97). 

Case  of  dermatitis  herpetiformis  in  a 
child,  3  years  of  age,  cured  by  circum- 
cision. The  disease  was  being  kept  up  by 
the  reflex  irritation  caused  by  phimosis. 
J.  N.  Roussel  (New  Orleans  Med.  and 
Surg.  Jour.,  June,  1900). 

Patholo^.  —  The  pathological  his- 
tology of  dermatitis  herpetiformis  has 
been  most  thoroughly  studied  by  Gil- 
christ, and  the  histological  characters  of 
the  affection  are  shown  in  the  illustra- 
tions on  page  414,  representing  sections 
from  a  case  of  dermatitis  herpetiformis 
(Duhring). 


numbers  of  polynuclear  leucocytes  are 
massed  in  the  papilla;,  having  replaced 
the  normal  tissue. 

Post-mortem  in  a  case.  1.  Absence  of 
bacterial  specificity  in  contents  of  bullee. 
2.  Coincidence  noted  by  Brocq  of  lesioni 
of  nervous  system.  3.  Co-existence  of 
bullous  lesions  and  nephritis.  Gastou 
(T,e  Bull.  Med.,  Apr.  21,  '95). 

Diagnosis. — The  multiformity  of  the 
lesions  and  the  tendency  to  their  herpetic 
arrangement,  which  Duhring  regards  as 
characteristic;  the  chronicity  of  the  dis- 
ease, and  its  frequent  recurrence;  the 
burning  and  itching,  and  general  ab- 
sence of  marked  constitutional  disturb- 


414 


DERMATITIS  HERPETIFORMIS.    DIAGNOSIS. 


ance  will  usually  enable  a  diagnosis  to  be 
made  without  difficulty.  Among  the  dis- 
eases which  may  cause  doubt  are  pem- 
phigus, herpes,  erj'thema  multiforme, 
and  eczema. 

Pemphigus. — The  lesions  are  usually 
well-formed  large  blebs,  rising  abruptly 


tended  by  moderate  pain  and  burning; 
no  itching;  the  blisters  are  usually  small 
and  aggregated  in  groups.  The  course 
of  the  disease  is  acute. 

Erythema  Multiforme.  —  In  this 
affection  there  are  rarely  vesicles,  blebs, 
and  pustules,  thoiigh  these  may  be  pres- 


^i=f.^i, 


fe\| 


'^i/i 


Sections  from  a  case  of  dermatitis  herpeliformis      (Qilclirist) 


from  a  normal  skin,  usually  discrete,  not 
attended  by  itching  or  burning,  and  dry- 
ing up  in  the  course  of  a  week.  Succes- 
sive crops  of  these  blebs  are  likely  to  ap- 
pear. 

Herpes. — The   lesions   are   vesicular, 
appear  upon  an  inflamed  base,  and  at- 


ent.  The  extremities  are  usually  at- 
tacked, and  the  distribution  of  the  erup- 
tion is  symmetrical.  The  color  of  the 
lesions  is  a  dusky  red  or  brownish;  no 
itching  and  but  slight  pain  and  burning. 
Eczema  may  cause  most  difficulty  in 
differentiation.    The  vesicles  in  this  dis- 


DERMATITIS  HERPETIFORMIS.    PROGNOSIS.    TREATMENT. 


415 


ease  are  usually  easily  ruptured  by 
scratching,  and  the  discharge  of  serum 
is  abundant.  Except  in  very  acute  cases, 
the  burning  sensation  is  not  as  severe  as 
in  D.  herpetiformis.  The  scratching  is 
followed  by  much  more  notable  excoria- 
tion in  eczema  than  in  the  disease  under 
consideration. 

Impetigo  heepetiformis  of  Hebra, 
which  was  at  first  regarded  by  Duhring 
as  merely  a  variety  of  D.  herpetiformis, 
is  now  conceded  by  him  to  be  a  distinct 
disease.  Its  lesions  are  always  pustular. 
It  nearly  always  occurs  in  pregnant 
women,  or  during  the  puerperal  period; 
is  attended  by  symptoms  of  grave  con- 
stitutional involvement,  and  generally 
terminates  fatally.  In  some  cases,  pro- 
longed observation  will  be  necessary  to 
make  a  definite  diagnosis. 

The  value  of  the  new  diagnostic  sign 
between  pempliigus  and  dermatitis  her- 
petiformis first  formulated  by  Leredde 
and  Perrin  confirmed.  This  consists  in 
the  simultaneous  presence,  in  the  latter 
disease,  of  eosinophile-cells  in  the  blood 
and  in  the  serum  of  the  bulla;.  In  two 
cases  examined  at  intervals  of  fifteen 
days  the  eosinophile-lcucocytes  and 
granules  were  found  in  abundance.  On 
the  contrary,  in  an  instance  of  pem- 
phigus foliaceus  the  eosinophile-cells 
were  entirely  absent  from  the  blood  and 
serum  on  the  first  and  second  examina- 
tions; also  at  an  interval  of  fifteen 
days;  in  the  blood  only  were  found  a 
very  few  cosinophile-leucocytes  con- 
taining well-stained  eosinophile-gran- 
ules.  Hallopeau  and  Lafitte  (Ann.  de 
Derm,  et  de  Syph.,  Dec,  '9G). 

Case  resembling  pemphigus  and  der- 
motitis  herpetiformis,  though  a  history 
of  recent  illicit  intercourse  seems  for  a 
time  to  have  raised  a  suspicion,  ap- 
parently erroneously,  of  syphilis.  It 
occurred  in  a  lad  of  21,  depressed  and 
slightly  feverish,  with  a  profuse  bullous 
eruption,  discrete  and  well  formed,  on 
the  lower  limbs,  but  sparingly  on  the 
trunk,  present  also  on  the  mucous 
membrane  of  the  mouth.     Itching  was 


marked.  In  the  course  of  two  or  three 
months  tlie  entire  body  became  attackea. 
With  this  there  was  a  dark-brown  pig- 
mentation and  a  disagreeable  odor,  and 
the  temperature  was  continuously  above 
101.5°  F.  No  e.vamination  for  eosino- 
phUes  was  made.  Riddle  (Jour.  Cutan. 
and  Genito-Urin.  Dis.,  May,  '97). 

Prognosis. — The  prognosis,  so  far  as 
life  is  concerned,  is  usually  favorable,  but 
the  disease  is  generally  chronic  in  dura- 
tion, and  has  a  marked  tendency  to  recur. 
Duhring  has  reported  cases  lasting  thir- 
teen and  fourteen  years. 

Treatment. — The  treatment  of  derma- 
titis herpetiformis  is  far  from  satisfac- 
tory. In  some  cases  the  lesions  yield 
promptly  to  local  applications,  while  in 
others,  as  Duhring  states,  the  lesions  de- 
velop, relapse,  and  recur  from  time  to 
time  in  spite  of  the  most  varied  measures 
employed.  The  internal  treatment 
should  be  directed  toward  the  improve- 
ment of  the  general  health,  and  the  ascer- 
tainment and  removal,  if  possible,  of  dis- 
ease or  disorder  of  the  stomach,  intes- 
tines, or  kidneys.  The  apparent  close 
connection  of  the  nervous  system  with 
the  etiology  of  the  disease  would  lead  one 
to  expect  benefit  from  neurotic  remedies, 
such  as  arsenic,  phosphorus,  and  str}-ch- 
nine.  Unfortunately,  neither  of  these 
can  be  relied  upon  in  all  cases,  though 
some  show  distinct  improvement  after 
the  use  of  the  first  named. 

Cannabis  Indica,  chloral,  opium,  and 
antipyrine  have  been  tried  as  sedatives 
and  anod}'nes;  but  little  benefit  can  be 
expected  from  them. 

Local  applications  likewise  are  often 
disappointing.  Dr.  Duhring  has  had 
most  success — in  the  vesicular,  bullous, 
and  pustular  forms — from  a  strong  sul- 
phur ointment,  3  drachms  to  the  ounce, 
applied  with  sufTicient  friction  to  rupt- 
ure the  lesions.  In  the  erythematous 
form  soothing  applications  are  indicated. 


416 


DERMATITIS  GAXGEKN'OSA.    DERMATITIS  IMALIGNA. 


Tar,  in  the  form  of  liquor  picis  alkalinus, 
1  drachm  to  8  ounces  of  water,  or  liquor 
earbonis  detergens  of  the  same  strength 
may  be  used  ■with  beneiit  in  some  cases. 
They  relieve  the  itching,  but  have  ap- 
parently little  influence  upon  the  prog- 
ress or  duration  of  the  eruption.  A  2- 
per-cent.  ointment  of  cocaine  is  also  of 
value  as  a  local  anodyne  when  the  burn- 
ing and  itching  are  severe. 

Ichthyol,  resorcin,  carbolic  acid,  sali- 
cylic acid,  and  thiol  have  been  used,  but 
without  much  success.  A  hot  bath  be- 
fore retiring  sometimes  gives  grateful  re- 
lief from  the  subjective  symptoms. 

In  dermatitis  herpetiformis  most  relief 
gained  by  lotions  of  chloroform-water, 
followed  by  dusting  with  powdered  talc 
and  inunction  with  a  calomel-and-bella- 
donna  ointment.  Dubreuilh  (Revue  de 
Th6r.  Medico-Chir.,  Mar.  1,  'S9). 

Case  of  a  man,  aged  51,  who  suffered 
from  general  furunoulosis  followed  by  a 
general  bullous  eruption.  The  author 
considered  it  a  malignant  form  of  der- 
matitis herpetiformis.  After  failure  of 
other  treatment,  cacodylate  of  soda  was 
given  up  to  20  centigrammes  (3  grains) 
daily.  This  was  afterward  changed  to 
hypodermic  injections.  After  several 
weeks  of  this  treatment  the  whole  dis- 
ease improved,  and  a  considerable  part 
of  the  body  became  healthy.  Davezac 
(Gaz.desHop.deToulouse,  July  13,1901). 

Dermatitis  Gan^enosa. 

Definition. — Inflammation  of  the  skin 
accompanied  by  sloughing  or  gangrene. 

Etiology.  —  Gangrene  or  sloughing 
may  follow  any  lesion  of  the  skin  severe 
enough  to  destroy  its  vitality.  Thus  it 
sometimes  follows  intense  or  long-con- 
tinued pressure,  severe  contusions,  vio- 
lent inflammation,  or  some  profound 
nervous  disturbance.  The  ordinary  bed- 
sore is  an  example  of  gangrenous  derma- 
titis from  pressure;  the  acute  or  neu- 
rotic bed-Bore  follows  a  neuritis  or  other 
disease  of  the  peripheral  nerves.    In  se- 


vere contusions,  the  application  of  caus- 
tics, deep  burns,  or  frost-bite  the  slough 
is  dxie  to  the  sudden  and  violent  arrest 
of  nutrition  in  the  part.  Diabetes  is  not 
rarely  accompanied  by  gangrene.  The 
interesting  affection  known  as  Raynaud's 
disease,  whose  most  marked  manifesta- 
tion is  symmetrical  gangrene  of  the  ex- 
tremities, cannot  properly  be  described 
as  a  gangrenous  dermatitis. 

A  gangrenous  dermatitis  of  infants  has 
been  described  under  various  names.  It 
occurs  most  frequently  after  varicella  in 
children  debilitated  by  innutrition  or 
constitutional  dyscrasise.  The  lesions 
consist  of  ulcerations  under  a  black 
slough  of  varying  thickness,  and  occupy- 
ing the  site  of  one  of  the  pustular  or  bul- 
lous lesions  of  the  disease.  The  same 
lesion  is  not  infrequently  observed  in 
vaccination,  especially  with  bovine 
lymph.  It  is  probable  that  the  gangrene 
is  due  to  an  infection  by  micro-organ- 
isms, but  the  nature  of  these  has  not 
been  determined.  This  form  of  local- 
ized gangrene  may  also  follow  other  skin 
diseases. 

Ten  cases  of  typhoid  fever  complicated 
by  gangrenous  dermatitis.  All  the  pa- 
tients were  young  men  who  went  out  as 
soldiers  in  the  Spanish  war.  Bacterio- 
logical examinations  from  unbroken 
vesicles  and  from  ulcers  showed  the 
staphylococcus  albus  and  aureus;  indif- 
ferent bacteria,  as  cocci  and  diplococ'ci, 
were  found  in  cultures  from  an  ulcer. 
The  disease  is  inoculable.  The  gangre- 
nous patches  appeared  on  the  trunk, 
face,  arms,  thighs,  and  in  two  instances 
on  the  scrotum.  The  extremities  were 
attacked  in  but  one  ease.  B.  F.  Stahl 
(Amer.  Jour.  Med.  Sci.,  Mar.,  IflOO). 

Treatment. — The  treatment  of  gan- 
grenous dermatitis  consists  in  the  appli- 
cation of  stimulant  and  antiseptic  lo- 
tions or  ointments. 

Dermatitis  Maligna. 

Definition. — An  inflammation  of  the 


DERMATITIS  MALIGNA.    SYMPTOMS.     PATHOLOGY. 


417 


skin  with  a  tendency  to  malignant  de- 
generation. 

Symptoms. — The  terms  "malignant 
dermatitis"  and  "malignant  papillary 
dermatitis"  are  applied  to  an  inflamma- 
tion, almost  exclusively  limited  to  the 
mammillary  portion  and  areola  of  the 
mammary  gland,  and  generally  known 
as  "Paget's  disease  of  the  nipple."  It  has 
much  the  appearance  of  an  eczema  ru- 
brum,  and  is  nearly  always  followed  by 
epitheliomatous  infiltration. 

Sir  James  Paget,  who  first  described 
the  affection  in  a  classical  paper  in  the 
St.  Bartholomew's  Hospital  Eeports  for 
1874,  gives  the  following  account  of  its 
clinical  history: — 

"The  patients  were  all  women,  vary- 
ing in  age  from  40  to  60  or  more  years, 
having  in  common  nothing  but  their  dis- 
ease. In  all  of  them  the  disease  began 
as  an  eruption  on  the  nipple  and  areola. 
In  the  majority  it  had  the  appearance  of 
a  florid,  intensely-red,  raw  surface,  very 
finely  granular,  as  if  nearly  the  whole 
thickness  of  the  epidermis  were  removed; 
like  the  surface  of  very  acute  diffuse  ec- 
zema, or  like  that  of  an  acute  balanitis. 
From  such  a  surface,  on  the  whole  or 
greater  part  of  the  nipple  or  areola,  there 
was  always  copious,  clear,  yellowish, 
viscid  exudation.  The  sensations  were 
commonly  tickling,  itching,  and  burn- 
ing, but  the  malady  was  never  attended 
by  disturbance  of  the  general  health.  I 
have  not  seen  this  form  of  eruption  ex- 
tend beyond  the  areola,  and  only  once 
have  seen  it  pass  into  a  deeper  ulceration 
of  the  skin  after  the  manner  of  a  rodent 
ulcer.  .  .  .  But  it  has  happened 
that,  in  every  case  which  I  have  been 
able  to  watch,  cancer  of  the  mammary 
gland  has  followed  within,  at  most,  two 
years,  and  usually  within  one  year.  The 
eruption  has  resisted  all  treatment,  both 
local  and  general,  that  has  been  used,  and 


has  continued  even  after  the  affected 
part  of  the  skin  has  been  involved  in  the 
cancerous  disease." 

The  only  fact  that  can  be  added  to 
this  description,  after  twenty-four  years' 
further  observation,  is  that  the  disease  is 
not  exclusively  located  upon  the  nipple 
of  women,  but  that  it  may  involve  the 
nipple  of  the  male  or  may  occur  upon 
other  portions  of  the  body.  The  in- 
flamed patch  of  the  nipple  and  areola  is 
usually  decidedly  indurated,  with  an  ele- 
vated border,  and  gives  the  sensation, 
when  pinched  up,  of  a  button  inserted  in 
the  skin. 

Pathology. — It  is  not  definitely  known 
whether  the  disease  is  epitheliomatous 
from  the  start,  or  whether  it  begins  as  an 
eczematous  dermatitis  and  becomes  ma- 
lignant in  consequence  of  the  epithelio- 
matous degeneration  of  the  skin.  The 
glandular  structures  of  the  nipple  are 
especially  liable  to  malignant  degenera- 
tion, and  it  is  probable  that  any  long- 
continued  irritation  of  the  epithelial  ele- 
ments would  be  followed,  in  persons  with 
a  predisposition  to  epithelial  overgrowth, 
by  malignant  disease.  Upon  this  as- 
sumption, the  view  that  the  primary  dis- 
ease is  an  eczema  or  a  dermatitis,  and 
that  malignancy  is  secondary,  is  a  ra- 
tional one. 

Microscopical  studios  of  the  disease  by 
Thin  and  Wile  have  shown  the  epithelial 
Infiltration  present  at  a  very  early  stage. 
It  may  be  said,  however,  that  when  the 
diagnosis  of  malignant  dermatitis  or 
Paget's  disease  can  be  made,  the  trouble 
is  no  longer  an  eczema,  whatever  it  may 
have  been  at  an  earlier  period. 

Case  of  iiiaUgnnnt  papillary  derma- 
titis occurring  on  the  breast  of  a  woman 
of  45.  The  morbid  changes  are  inflam- 
mation of  the  papillary  layer,  with 
(cdema  and  vacuolation  of  the  epidermic 
cells,     the     latter     being     followed     by 


418 


DERAIATITIS  ilALIGNA.    DERMATITIS  EXFOLIATIA'A. 


complete  destruction  or  by  abnormal 
proliferation  in  different  situations.  Sec- 
ondary to  these  changes  there  is  pro- 
liferation of  the  lining  of  the  galaetif- 
erous  ducts  and  glands.  The  prolifer- 
ated cells  finally  break  through  the 
basement-membrane  into  the  surround- 
ing tissue,  at  which  point  malignant  in- 
fection begins.  F.  H.  Wiggin  and  J.  A. 
Fordyce  (N.  Y.  Med.  Jour.,  Oct.  2,  '97). 

Diagnosis.  —  Diagnostic  features  of 
malignant  dermatitis  as  differentiated 
from  eczema  of  tlie  nipple  are: — 

1.  Its  occurrence  in  women  over  40 
years  of  age,  while  eczema  of  the  nipple 
is  more  frequent  in  the  child-bearing  age, 
and  especially  during  lactation. 

2.  The  affected  surface  is  red,  raw, 
and  granular-looldng. 

3.  There  is  decided  superficial,  well- 
defined  induration  in  place  of  the  dif- 
fuse, leathery  infiltration  of  eczema. 

Finally,  while  eczema  is  often  ob- 
stinate, it  usually  yields  to  proper  local 
treatment;  while  malignant  dermatitis 
is  not  curable  by  any  means  short  of 
cauterization  or  removal  with  the  knife. 

Treatment, — In  reference  to  the  treat- 
ment of  malignant  dermatitis,  Sir  James 
Paget  said  in  his  paper  above  referred  to: 
"In  practice  the  question  must  be  some- 
times raised  whether  a  part,  through 
whose  disease  or  degeneracy  cancer  is 
very  likely  to  be  induced,  should  not  be 
removed.  In  the  member  of  a  family  in 
which  cancer  has  frequently  occurred, 
and  who  is  at  or  beyond  middle  age,  the 
risk  is  certainly  very  great  that  such  an 
eruption  on  the  areola,  as  I  have  de- 
scribed, will  be  followed  within  a  year  or 
two  by  cancer  of  the  breast.  Should  not, 
then,  the  whole  diseased  portion  of  the 
skin  be  destroyed  or  removed  as  soon  as 
it  appears  incurable  by  milder  means?" 

The  answer  to  tlie  question  is  self-evi- 
dent, in  view  of  the  history  of  the  dis- 
ease.   If  a  diagnosis  of  malignant  derma- 


titis is  positively  made,  there  can  be  no 
other  rational  treatment  than  such  as 
would  be  appropriate  for  epithelioma; 
namely:  destruction  of  the  diseased  skin 
by  cautery  or  caustics,  or  removal  of  the 
entire  breast.  In  cases  of  doubt,  the  ap- 
proved remedies  for  eczema  may  be  tried, 
but  too  much  time  should  not  be  wasted 
in  temporizing  expedients. 

Pyrogallic-acid  ointment,  3  drachms 
to  the  ounce;  lactic  acid;  chloride-of- 
zinc  paste,  of  varying  strength;  chromic- 
acid  and  arsenical  pastes,  the  best  of 
which  is  Marsden's  (IJ  acidi  arsenosi, 
pulv.  g.  acaciffi,  of  each,  p.  e.;  mix  and 
make  a  stiff  paste  with  water  just  before 
using),  may  all  be  used  with  good  effect. 
Chromic  acid  in  concentrated  solution  is 
the  least — Marsden's  paste  the  most — 
painful  of  these  applications.  The  ar- 
senical paste  should  not  be  applied  over 
a  surface  of  more  than  one  sqtiare  inch 
at  a  time,  as  otherwise  sufficient  arsenic 
may  be  absorbed  to  cause  symptoms  of 
poisoning.  The  pain  of  the  application 
is  very  severe,  and  as  the  caustic  must 
remain  upon  the  part  at  least  twenty-four 
hours,  the  suffering  is  always  consider- 
able. Wlien  the  paste  is  applied  a  piece 
of  lint  is  pressed  upon  it  which  absorbs 
the  surplus  and  prevents  its  spreading. 
After  twenty-four  hours,  a  poultice  is 
applied,  which  soon  causes  a  separation 
of  the  slough.  The  resulting  ulcer  is 
usually  healthy  in  appearance  and  heals 
readily  under  simple  applications,  if  all 
the  degenerated  tissue  has  been  de- 
stroyed. 

The  galvanocautery  and  thermocaii- 
tery  are  trustworthy  methods  for  destroy- 
ing the  morbid  tissue. 

When  the  area  involved  is  large,  the 
best  treatment  is  thorough  extirpation 
of  the  entire  Ijreast. 

Dermatitis  Exfoliativa. 

Definition. — Tiiflanimiitinn  of  the  skin, 


General  Epidemic  Exfoliative  Dermatitis  iByrom  Bramwell.l 


»S     OF    CLINICAL     MCDICINE 


DERMATITIS,  ACUTE  EXFOLIATIVE.    SYMPTOMS.    DIAGNOSIS. 


419 


acute  or  chronic,  accompanied  by  exfolia- 
tion of  the  epidermis. 

Varieties.  —  (A)  Acute  exfoliative 
dermatitis  of  infants. 

(B)  Chronic  general  exfoliative  derma- 
titis. 

(C)  Local  exfoliative  dermatitis. 
{D)  Epidemic  exfoliative  dermatitis. 
(A)  Acute  Exfoliative  Dermatitis  of 

Infants. 

Defnition.  —  An  acute  inflammatory 
affection  of  the  skin  of  infants,  accom- 
panied by  exfoliation  of  the  epidermis 
in  flakes,  running  a  rapid  course,  and  in 
most  cases  ending  fatally. 

Symptoms. — The  disease  was  first  de- 
scribed by  Prof.  Bitter  von  Eittershain, 
of  Vienna.  He  had  observed  nearly 
three  hundred  cases  in  the  course  of  ten 
years. 

The  children  attacked  were  nearly  all 
between  3  and  5  weeks  old.  A  pro- 
dromal stage,  characterized  by  abnormal 
dryness  of  the  integument,  with  furfu- 
raceous  epidermal  desquamation,  usually 
occurred.  The  skin  of  the  lower  part  of 
the  face,  especially  about  the  angles  of 
the  mouth,  becomes  red  and  slightly 
tumid.  The  margin  of  the  redness, 
which  rapidly  spreads,  is  indistinct,  not 
being  sharply  defined  against  the  healthy 
skin.  The  skin  at  the  angles  of  the 
mouth  becomes  fissured  and  covered  with 
scabs.  The  mucous  membrane  lining  the 
pharynx  and  buccal  cavity  is  reddened, 
and  the  palatal  arch  is  the  seat  of  super- 
ficial erosions,  covered  by  a  grayish-white 
exudation. 

The  appetite  and  digestion  remain  un- 
impaired. There  is  no  fever.  The  red- 
ness and  thickening  of  the  skin  extend 
over  the  entire  body.  The  face  becomes 
covered  by  yellowish,  translucent  scabs 
upon  a  reddened  base,  intersected  in  vari- 
ous directions  by  fissures.  The  skin  be- 
comes wrinkled,  and  the  upper  layer  sep- 


arates from  the  cutis.  The  epidermis 
may  be  detached  in  large  flakes  or  in 
scales.  This  process,  continuing  until 
the  entire  surface  is  denuded  of  epi- 
dermis, presents  an  appearance  similar  to 
that  following  an  extensive  scalding.  In 
favorable  cases  the  dark,  raw-flesh  color 
of  the  cutis  soon  gives  way  to  a  lighter 
red,  and  in  some  cases  the  normal  color 
of  the  skin  is  restored  in  twenty-four  to 
thirty-six  hours.  In  unfavorable  cases, 
on  the  other  hand,  the  color  is  a  dirty 
brownish-red,  and  the  cutis  becomes  dry 
and  parchment-like.  In  those  cases 
which  terminate  in  recovery,  the  normal 
condition  is  entirely  re-established  in  a 
week  or  ten  days,  the  skin  for  a  few  days 
being  covered  by  a  fine,  branny  desqua- 
mation. 

As  sequels,  eczemas  of  considerable  ex- 
tent, or  small,  superficial  boils  and  ab- 
scesses, sometimes  in  large  numbers,  oc- 
cur, and  delay  recovery.  At  other  times 
extensive  phlegmonous  infiltrations  oc- 
cupy considerable  tracts  of  skin,  and  may 
result  in  gangrenous  destruction  of  tis- 
sue and  death.  In  the  latter  conditions 
pneumonia  and  colliquative  diarrhcea  not 
rarely  precede  the  fatal  termination.  Re- 
lapses are  rare.  The  disease  is  ascribed 
to  a  septic  or  pus  infection  localized  upon 
the  skin. 

Diagnosis. — In  typical  cases,  no  ditfl- 
culty  should  occur  in  diagnosis.  Ery- 
sipelas, which  sometimes  closely  resem- 
bles this  disease,  is  easily  excluded  by  the 
high  temperature  of  the  former.  In 
pemphigus  there  are  distinct  bulls  sepa- 
rated by  normal  skin.  In  exfoliative 
dermatitis  the  redness  and  thickening 
are  progressive  and  finally  occupy  the 
entire  surface. 

Case  of  dcniiatitis  exfoliativa  pig- 
mentosa in  which  the  disease  hore  a 
close  resemblance  to  the  pityriasis  rulira 
of  Devergie.  with  the  exception  of  the 
pigmentation,   which   was  very   intense. 


420 


DERMATITIS,  CHROXIC  EXFOLIATI^■E.    SYJIPTOMS. 


Henry  Handford   (Brit.  Jour,  of  Derm., 
Mar.,  '94). 
Prognosis. — This   is   decidedly   unfa- 
vorable.   In  Eittershain's  cases  the  mor- 
tality was  about  50  per  cent. 

Treatment. — Xo  internal  treatment  is 
indicated  in  uncomplicated  cases.  Suffi- 
cient nourishment  is,  of  course,  impor- 
tant. Locally,  cool  baths,  or  bran-baths, 
afterward  drying  the  skin  with  fine,  soft 
cloths  and  carefully  avoiding  friction, 
will  meet  the  indications  in  most  cases. 
Eagged  and  loose  patches  of  epidermis 
should  be  clipped  o£E  with  scissors,  and 
all  denuded  and  fissured  surfaces  dusted 
with  finely-powdered  calomel.  The 
crusts  which  accumulate  at  the  angle  of 
the  mouth  and  render  nursing  difficult 
and  painful  are  best  got  rid  of  by  soak- 
ing with  oil  of  sweet  almonds  and  care- 
fully removing  the  loose  ones  by  means 
of  dressing-forceps.  Slightly  astringent 
baths  (decoction  of  oak-bark,  1  pint  to 
the  bath)  are  sometimes  beneficial. 

The  most  efficacious  treatment  is  the 
creolin  bath:  about  15  gallons  of  com- 
fortably-warm water  at  95°  F.,  to  which 
2  Vs  pints  of  a  1-per-cent.  solution  of 
ereolin  are  added.  A  bath  is  taken  regu- 
larly once  a  day — in  very  bad  cases  twice 
— remaining  in  it  twenty  minutes.  It 
is  best  given  at  night,  the  patient  being 
subsequently  dried  and  put  to  bed. 

Creolin  ointment  ('A,  1.  and  2  per 
cent.,  rubbed  with  lanolin  and  water  in 
almost  equal  parts)  ranks  ne.xt  to  creo- 
lin baths  in  ellicacy,  especially  if  used 
in  quite  an  early  stage.  Savill  (Edin- 
Ijurgh  Med.  Jour.,  Apr.,  '95). 
(B)  Chronic  General  Exfoliative  Der- 
matitis. 

Definition.  —  A  chronic  generalized 
dermatitis,  accompanied  by  constant  ex- 
foliation of  the  epidermis  in  dry,  papery 
scales:   the  pityriasis  rubra  of  Ilebra. 

Symptoms. — The  disease  begins  with 
the  appearance  of  red  patches,  gradually 
increasing  in  size,  uniting  with  others 
until  finally  the  entire  surface  is  a  sheet 


of  red,  dry  skin.  There  is  no  thickness 
or  infiltration.  In  about  a  week  the  epi- 
dermis begins  to  scale  off  in  large,  thin, 
white  or  grayish  scales,  which  soon  be- 
come very  profuse  and  shed  in  large 
sheets.  The  skin,  at  the  same  time  be- 
comes of  a  dusky-  or  brownish-  red.  The 
inguinal  glands  also  enlarge.  Later  the 
skin  becomes  infiltrated  to  some  extent, 
and  looks  tense  and  shiny  in  places.  The 
mouth  becomes  puckered,  and  the  skin 
of  the  joints  may  be  fissured  and  some- 
times moist.  There  may  also  be  boils  or 
pustules,  the  hair  may  fall  out,  and  the 
nails  atrophy  and  exfoliate.  There  is 
often  fever  at  the  beginning  and  at  in- 
tervals during  the  course  of  the  disease. 
There  is  little  itching.  The  subjective 
symptom  mostly  complained  of  is  a  sen- 
sation as  if  the  skin  were  too  small,  and 
the  patient  frequently  is  chilly. 

The  cotirse  of  the  disease  is  chronic, 
lasting  months  or  years,  with  exacerba- 
tions of  greater  severity,  alternating  with 
remissions. 

There  is  usually  progressive  emacia- 
tion, and  the  patient  dies  of  inanition,  or 
is  carried  off  by  some  intercurrent  affec- 
tion.   Happily  the  disease  is  rare. 

Case  of  dermatitis  exfoliativa  in  an 
infant,  which  appeared  on  the  tenth, 
day  of  life  and  gradually  (five  weeks) 
spread  over  the  entire  body.  It  was 
characterized  by  dilTuse  redness,  more- 
intense  in  some  places  than  in  others, 
and  by  foliaceous  desquamation.  Small 
vesicles  also  appeared.  The  eruption 
caused  itching,  but  did  not  interfere 
with  the  patient's  general  condition. 
There  were  no  lesions  in  the  mouth,  and 
the  hair  fell  in  certain  spots.  Raymond 
and  Barbe  (Le  ProgrCs  MC'd.,  Jan.  23, 
'92). 

Case  of  dormatitia  exfoliativa  in  a  girl 
aged  11  years.  She  was  first  seized  with 
fever  and  nausea.  Three  days  later  her 
tongue  was  heavily  coated,  the  breath 
oirensivc,  and  sores  were  present.  The- 
face,  neck,  and  upper  chest  presented  a. 


DERMATITIS:   LOCAL  EXFOLLAiTIVE,  EPIDEiUC  EXFOLIATIVE. 


421 


scalded  appearance,  the  epidermis  being 
lifted  from  the  true  skin,  rolling  up  like 
tissue-paper,  and  being  broken  in  a 
number  of  places.  The  temperature  was 
103°  F.;  the  pulse  144.  The  disease 
pursued  its  usual  fatal  course,  carrying 
off  the  patient  two  days  later.  No 
drug  was  held  accountable  for  the  symp- 
toms. H.  M.  Beatty  (Archives  of  Fed., 
Feb.,  '90). 

The  cause  of  chronic  general  exfolia- 
tive dermatitis  is  not  kno^vn. 

Diagnosis. — The  only  disease  likely  to 
be  mistaken  for  chronic  exfoliative  der- 
matitis is  scaly  eczema.  Still,  this  is 
never  so  universally  distributed;  has  usu- 
ally a  history  of  moisture  and  exudation 
at  some  time  in  its  course;  is  attended  by 
intense  itching  and  considerable  infiltra- 
tion. Lichen  planus  is  a  papular  dis- 
ease, and,  while  the  papules  are  some- 
times aggregated  in  solid  sheets,  has  a 
different  history  from  this  disease. 

Treatment. — The  treatment  is  unsatis- 
factory. Arsenic,  which  seems  indicated, 
has  little  effect  on  the  course  of  the  erup- 
tion. Good  results  are  sometimes  ob- 
tained from  codliver-oil,  both  internally 
and  externally.  Saline  diuretics  and 
aperients  are  occasionally  beneficial. 
Externally  bland  ointments  may  be  ap- 
plied. The  extensive  surface  involved 
prohibits  the  use  of  mercurial  applica- 
tions, as  salivation  would  be  likely  to 
follow.  Glycerite  of  starch  or  Lassar's 
paste  may  at  times  relieve  the  uncom- 
fortable sensation  of  tightness  of  the 
skin. 

(C)  Local  Exfoliative  Dermatitis. 

Definition. — A  localized  dermatitis  of 
mild  character,  occurring  in  rounded  or 
oval  spots;  rosy,  red,  or  mottled  in  color, 
and  attended  by  furfuraceous  desquama- 
tion. It  is  the  pityriasis  rosea  of  Gilbert 
and  Duhring. 

Symptoms. — The  most  thorough  study 
of  the  disease  in  this  country  is  by  Duhr- 


ing. It  begins  with  the  eruption  of  small 
macular  or  maculo-papular  lesions,  of  a 
rosy  or  reddish  color,  sharply  defined 
against  the  surrounding  skin,  being 
sometimes  on  a  level  with  it,  sometimes 
slightly  raised,  and  sometimes  depressed. 
The  patches  are  covered  with  fine,  branny 
scales  and  spread  at  the  margin  while 
healing  in  the  centre.  The  subjective 
symptoms  are  usually  slight,  only  mod- 
erate itching  being  sometimes  com- 
plained of.  The  disease  lasts  from  one 
to  three  months,  recovery  taking  place 
spontaneously 

Causation. — It  is  apparently  a  vege- 
table parasitic  affection,  but  no  charac- 
teristic parasite  has  been  demonstrated 
in  the  skin  or  the  scales. 

Diagnosis. — The  erythematous  syphi- 
lide  most  nearly  resembles  this  affection. 
The  history  of  the  case  or  observation 
of  the  patient  for  a  week  or  two  will 
clear  up  the  diagnosis. 

Treatment. — Lassar's  paste  or  other 
mild  salicylic-acid  or  carbolic-acid  oint- 
ment may  be  used.  Sulphur  is  also 
recommended.  As  the  disease  gets  well 
of  itself  in  a  short  time,  not  much  atten- 
tion need  be  given  to  the  treatment. 

(D)  Epidemic  Exfoliative  Dermatitis. 

This  has  recently  been  described  by 
Thomas  Savill,  of  London,  who  ob- 
served a  large  number  of  cases  in  the 
Paddington  Infirmary.  The  disease  be- 
gins as  an  erythematous  or  papular 
eruption,  spreading  peripherally  like 
ringworm.  This  is  followed  by  exuda- 
tion and  desquamation.  The  skin  is  red, 
thickened,  and  indurated,  the  epidermis 
being  shed  in  flakes  or  scales.  There  is 
moist  exudation  in  most  cases,  especially 
in  the  flexures  of  the  joints  or  behind 
the  ears.    Exfoliation  is  continuous. 

As  the  disease  subsides,  the  skin  be- 
comes brownish,  indurated,  and  thick- 
ened, and  mav  be  smooth  and  shinv  or 


422 


DEKM.\TITIS,  EPIDEMIC  EXFOLIATIVE. 


'^^i^'i^J^'^'^ 


\ 


Fig.  2. 
Epidemic  exfoliiiUvc  ilcnMiiUtis:    Ravill's  disease.     {KmlHn  Echeverria.) 
Fig.   1. — Lfiw  power.     <i,  Clear    Hiiperficial  layer  of  epidermis;    h,  darkly-stained,  deep 

laj'cr  of  epidermis;  e,  periglandular  enlarfjenient  of  coil-elands. 
Fi/,'.   2. — Leitz   oil    immersion,   '/w     «,   lloiny    layer;     h,    middle    layer    of   epidermis, 
showing  peridiaphnnia  of  nuclei  and  swclliiij,'  of  cell-protoplasm;    c,  lowest  layer, 
showing  hypcrtrophied  nuclei. 


DERMATITIS. 


DIABETES  INSIPIDUS. 


433 


cracked.  The  hair  and  nails  fall.  There 
is  itching  and  burning,  sometimes  severe. 
Albuminuria  is  frequent  (50  per  cent,  of 
cases).  There  may  be  fever,  although 
this  is  usually  not  high.  It  is  most  fre- 
quent in  adults,  generally  in  those  of 
advanced  age. 

Dermatitis  exfoliativa  is  the  only  skin 

malady  which,  up  to  the  present  time, 

has  been  connected  with  epidemic  causes. 

In   some   respects   it   resembles   eczema. 

Distinctive  points:  — 


1.  Attnclts  (ill  ftgea,  and  chil- 
dren are  vory  liablo. 
'2.  Gout  ifl'a  marked  prodispoa- 


Epldo 


1  exfolii 

in  sointt  places  without  previous 
emptirin.  Dermal  thickening 
gencally  present. 

5.  Course  fairly  definite. 

6.  Undoubtedly  cent BKi on 8 
and  epidemic  utidor  certain  con- 


3.  Constitutional  dia 
always  moderate,  and 
fatal. 

4.  Dried  crusts  thrown  olT.  but 
•  ifoliatlon  of  cuticle  not  a 
marked  feature  of  the  disease. 
Dermal  thickening  absent  or 
moderate. 

5.  Course  not  deSnite. 

6.  Not  liithort.*  regarded  as 
contagious  or  epidemic. 

Savill    (Edinburgh    Med.    Jour.,   Apr., 
'95). 
Prognosis. — This  is  grave.    In  Savill's 
experience  over  12  per  cent.  died.  | 

Etiology. — This  is  not  known,  though 
from  its  epidemic  prevalence,  apparent 
contagiousness,  and  great  fatality  it 
seems  to  be  due  to  some  infectious  organ- 
ism. This  has,  however,  not  yet  been 
demonstrated. 

Pathology.  —  A  careful  histological 
study  of  the  changes  in  the  skin  has  been 
made  by  Emilio  Echeverria  (see  illustra- 
tions), who  concludes  that  the  essential 
histological  changes  in  the  disease  are 
superficial  and  to  be  found  mainly  in  the 
epidermis.  The  cutis  is  rarely  affected 
to  any  extent.  According  to  Echeverria, 
the  disease  is  rather  an  epidermatitis 
than  a  dermatitis.  He  has  found  a  pe- 
culiar diaphanous  degeneration  of  the 
prickle-cell  layer  of  the  epidermis,  which 
he  regards  as  characteristic. 

In  blnstomycetic  dermatitis  there  is 
a  sharply-raised,  well-defined,  slightly- 
elevated  border,  composed  of  minute 
verruciform      projections,      commingled 


with  small  purulent  points,  from  which 
pus  can  be  expressed.  On  the  side  of 
the  sound  skin  there  is  a  bluish-red, 
sloping  border,  with  pin-point-sized  ab- 
scesses, not  closely  set;  while  on  the 
morbid  side  of  the  inclosing  wall  ia 
either  a  moist,  granulating  surface  or 
a  partially-cicatrized  reddish  and  tender 
disk,  with  here  and  there  projecting 
areas  made  up  of  the  verrucous  eleva- 
tions. The  regions  of  preference  are, 
first,  the  face;  next,  the  lower  limbs; 
then,  in  order  of  frequency,  the  hand, 
leg,  foot,  scrotum,  and  back.  One-half 
of  the  cases  showed  multiplicity  of 
lesions  in  other  parts  of  the  body,  - 
suggesting  autoinoculability.  Evidence 
favors  the  view  that  the  medium  of  in- 
fection lodges  on  the  hand  or  face,  and 
from  thence  is  transferred  to  some  ac- 
cessible spot.  Hj'de  and  Ricketts  (Jour. 
Cutan.  and  Genito-Urin.  Dis.,  Jan., 
1901). 

Report  of  a  case.     Positive  and  un- 
questioned diagnosis  between  blastomy- 
cetic   dermatitis   and  certain   forms   of 
cutaneous  tuberculosis  can  scarcely  be 
made     without    histological     and     bac- 
teriological   investigations.      Stelwagon 
(Amer.  Jour.  Med.  Sci.,  Feb.,  1901). 
Treatment. — Savill    obtained    most 
benefit  from  creolin-baths   (2  Vs  pints 
of  a  1-per-cent.  solution  in  a  bath  of  15 
gallons  of  water  at  95°  F.)  or  creolin 
ointment  CA,  1,  and  2  per  cent.).    The 
baths  should  be  given  once  or  twice  a 
day. 

George  H.KoHE  (Baltimore)  and 
Central  Staff  (Philadelphia). 

DIABETES  INSIPIDUS  (POLY- 
TTRIA). 

Definition.  —  A  disease  characterized 
by  marked  increase  in  the  quantity  of 
urine,  without  any  important  qualitative 
changes  in  the  elements  of  which  it  is 
composed. 

Symptoms. — The  malady  may  begin 
insidiously;  but  it  is  not  unusual  for  it 
to  appear  suddenly,  either  following  one 
of  tlie  causes  which  we  shall  name  later 


424 


DIABETES  IKSIPIDUS.    SYMPTOMS. 


on,  or  even  without  any  appreciable 
cause.  It  may,  in  exceptional  cases, 
manifest  itself  during  childhood  or  in- 
fancy. 

[I  have  lately  had  under  observation 
a  Toung  man,  IG  years  old,  who  was 
subject  to  excessive  thirst,  since  the  first 
months  of  his  life,  the  first  word  he 
pronounced,  at  the  age  of  S  months, 
being  "  ira to-."     E.  Lepixe.] 

When  diabetes  insipidus  is  not  a 
primary  disease,  it  may  depend  upon 
some  nervous  affection. 

The  urine  is  abundant,  usually  very 
pale  in  color,  and  is  slightly  acid.  The 
specific  gravity  varies  from  1003  to  1010. 
Consequently,  the  organic  and  inorganic 
principles  are  not  present  in  any  great 
quantity,  but,  taking  into  account  the 
daily  amount  of  urine,  it  will  be  found 
that  the  total  quantity  of  organic  and  in- 
organic substances  usually  considerably 
exceeds  the  normal  average.  With  re- 
gard to  the  relative  proportions,  the 
chlorides  are  increased. 

In  inducing  unilateral  polyuria  in  a 
dog,  for  instance,  by  severing  a  splanch- 
nic nerve,  I  have  likewise  observed  the 
relative  increase  of  the  chlorides.  This 
fact  proves  that  the  relative  increase  re- 
sults from  an  elective  permeability  of 
the  kidney  with  regard  to  these  salts. 

The  quantity  of  urine  voided  during 
the  twenty-four  hours  naturally  bears 
a  certain  relation  to  the  quantity  of 
liquid  ingested.  As  the  cutaneous  per- 
spiration is  usually  greatly  diminished 
in  diabetic  patients,  there  is,  as  a  rule, 
less  difference  than  in  the  normal  state, 
between  the  quantity  of  fluid  taken  and 
that  of  the  urine. 

It  is  even  possilile  that,  in  exceptional 
cases,  the  quantity  drank  in  one  day 
may  be  less  than  that  of  tlio  urino  voided 
during  the  same  time. 

In  explanation  of  this  panulox  there 
are  three  hypotheses: — 


The  first  (which  is  the  most  natural) 
is  the  supposition  that  during  this  period 
the  economy  becomes  impoverished  as 
to  water.  This  hypothesis  agrees  with 
several  conditions  sometimes  noticed  in 
polyuric  subjects,  particularly  the  in- 
creased density  of  the  blood;  in  tliis 
case  the  weight  of  the  patient  should  be 
less  during  the  period  in  question.  The 
second  hypothesis,  which,  though  not 
based  on  any  special  fact,  does  not  seem 
irrational,  premises  that  there  is  a  much 
greater  formation  of  water  in  the  econ- 
omy than  in  the  normal  conditions.  In 
this  case,  there  should  be  a  diminution 
in  the  respiratory  quotient;  ?°\  It  is 
evident  that,  if  there  is  more  water 
formed,  there  is  less  CO,  exhaled.  This 
fact  has  been  observed  in  certain  condi- 
tions of  infectious  fevers. 

The  third  hypothesis  appears  to  be 
less  plausible.  It  consists  in  the  sup- 
position that  the  economy  may  absorb, 
particularly  through  the  lungs,  a  certain 
quantity  of  watery  vapor.  It  is  known 
that  in  the  healthy  subject  a  copious 
ingestion  of  watery  fluid  is  followed, 
during  the  two  consecutive  hours,  by  the 
loss,  in  the  urine,  of  the  greater  part  of 
the  water  taken.  The  same  is  not  the 
case  in  diabetes  insipidus;  the  elimina- 
tion is  less  rapid,  either  because  the  kid- 
ney has  partially  lost  its  functional  elas- 
ticity, which  enabled  it,  in  the  normal 
state,  to  free  the  blood  from  an  excess 
of  water,  or  rather  because  the  economy, 
being,  relatively  speaking,  deprived  of 
water,  takes  up  a  certain  portion  of  that 
ingested. 

In  the  same  connection  it  may  be 
noted  that  in  the  polyuric  subject  the 
difference  existing  in  tlie  healthy  person 
])ctwccn  the  urine  of  the  twelve  hours 
of  tbe  day  and  those  of  the  night  is  not 
noticeable. 

Falck  advanced  the  opinion  that  ab- 


DIABETES  INSIPIDUS.    DIAGNOSIS. 


425 


eorption  is  retarded  in  polyuric  patients. 
This  supposition  is,  in  general,  not  very 
likely,  but  I  would  say  that  the  dilata- 
tion of  the  stomach  sometimes  observed 
in  such  patients  might  confirm  it  in  cer- 
tain cases. 

Thirst  is  a  very  marked  symptom, 
which,  in  certain  exceptional  cases 
classed  under  the  head  of  polydipsia,  is 
the  original  symptom.  This  point  will 
be  again  referred  to  under  the  head  of 
Diagnosis. 

The  digestive  function  is  impaired  in 
polyuric  patients.  This  is  readily  under- 
stood, the  digestion  being  disturbed  by 
the  ingestion  of  a  large  quantity  of 
water,  which  dilutes  the  gastric  juice. 
Constipation  usually  exists. 

A  phenomenon  of  some  interest,  theo- 
retically speaking,  has  been  noticed  in 
some  quite  exceptional  cases,  namely: 
an  abnormal  flow  of  saliva.  Kiilz  ob- 
served this  condition  for  a  time  in  a 
young  hysterical  subject,  and  was  able 
to  collect,  in  one  day,  more  than  one  pint 
of  saliva. 

It  is  known  that  physiologists  have, 
during  their  experiments,  sometimes  ob- 
served salivation  in  dogs  and  rabbits, 
after  certain  lesions  of  the  medulla 
oblongata,  etc.  In  some  cases  the  pulse 
is  slow,  and  there  is  also  a  certain  rela- 
tion between  this  slowness  of  the  pulse 
and  the  increase  of  the  polyuria. 

The  blood  is  sometimes  more  concen- 
trated than  in  the  normal  state,  but  this 
is  by  no  means  a  constant  symptom; 
when  it  exists  it  would  seem  to  indicate 
an  exaggerated  permeability  of  the  kid- 
neys, and  the  inability  to  retain  the 
water  of  the  economy. 

The  bladder  is  larger  than  in  the  nor- 
mal state;  the  kidneys  may  also  be  rela- 
tively larger,  but  they  do  not  present 
any  structural  alterations. 


Altliough  in  some  cases  polyuria  un- 
acooiiipanied  with  glycosuria  is  a  com- 
paratively liarmless  affection,  yet  in 
otliers  tlie  condition  may  be  a  serious 
one,  attended  with  grave  alterations  in 
the  general  health,  and  leading  in  a  few 
years  to  death.  These  serious  cases  of 
polj'uria  are  believed  to  depend  upon  dis- 
ease of  the  pancreas.  Cases  of  polyuria 
run  a  much  more  rapid  course,  and  are 
much  more  fatal,  in  children  than  in 
grown-up  people.  Jlongour  and  Gentes 
(La  Presse  il6d.,  Dec.  20,  '99). 

Diagnosis. — This  usually  presents  very 
little  difficulty.  The  absence  of  abnor- 
mal principles  in  the  urine  indicates  by 
exclusion  the  existence  of  simple  poly- 
uria. It  may  happen,  however,  that  the 
diagnosis  between  this  condition  and 
that  of  interstitial  nephritis  gives  some 
little  trouble.  In  certain  cases  of  the 
last-named  affection  albuminuria  may 
not  exist  during  a  certain  period.  On 
the  other  hand,  there  are  cases  of  poly- 
uria in  which,  without  any  actual  ne- 
phritis, traces  of  albumin  may  be  found 
in  the  urine. 

However,  when  interstitial  nephritis 
exists,  certain  ursemic  symptoms,  hyper- 
trophy of  the  heart  or  some  one  of  the 
symptoms  of  Bright's  disease,  are  always 
present.  Besides  searching  for  the  symp- 
toms of  uraemia  (cephalalgia,  dyspnoea, 
etc.),  it  should  also  be  remembered  that 
a  patient  suffering  from  Briglit's  disease 
eliminates  less  nitrogen  in  his  urine  than 
polyuric  patients,  and  that  the  urine  fre- 
quently contains  casts.  In  view  of  these 
characteristics,  it  is  generally  easy  to  es- 
tablish a  diagnosis. 

Polyuria  presents  several  varieties: 
primary  polyuria  and  primary  polydipsia. 
How  are  these  to  be  distinguished? 

In  polydipsia  thirst  is  unquestionably 
the  first  symptom:  it  is  not  preceded  by 
frequent  micturition.  Polyuric  patients 
do  not  perspire;  in  polydipsia  perspira- 
tion is  likely  to  occur.     In  the  latter 


428 


DIABETES  INSIPIDUS.    ETIOLOGY. 


affection  the  quantity  of  urine  does  not 
amount  to  the  quantity  of  liquid  in- 
gested; so  that,  if  the  patient  refrain 
from  drinking  during  several  hours, 
there  wiU  be,  during  this  time,  a  diminu- 
tion or  even  an  arrest  of  the  excretion 
of  the  urine. 

Finally,  in  the  polydipsic  patient  the 
blood  is  more  rich  in  water,  -n-hile  in  the 
polyuric  it  is  more  concentrated. 

Etiology. — Diabetes  occurs  most  fre- 
quently in  middle  age,  but  polyuria  is 
not  rare  in  childhood.  In  some  families 
several  polyurics  will  be  found;  these 
are  usually  families  showing  a  neuro- 
pathic diathesis. 

Case  observed  in  a  girl,  16  years  old, 
who  suffered  from  diabetes  insipidus, 
Tvho  belonged  to  a  family  in  which  the 
disease  was  hereditary.  Four  genera- 
tions and  8  out  of  19  members  of  the 
family  had  suffered  from  polyuria,  viz.: 
the  great-grandmother,  3  of  her  children, 
3  grandchildren,  and  the  great-grand- 
child,— the  patient.  The  disease  was,  in 
all  cases,  directly  inherited  by  the  child 
from  its  parent,  all  the  first-bom  being 
attacked.  The  great-grandfather  suf- 
fered from  enuresis,  but  not  from  poly- 
uria. Lauritzen  (Hospitalstidende,  p. 
353,  '93). 

Study  in  metabolism  on  two  cases  of 
diabetes  insipidus  in  a  man  of  47  and 
a  girl  of  14  years  showed  that  they  did 
not  eliminate  more  water  in  the  urine 
than  they  ingested;  insensible  perspira- 
tion was  practically  normal,  contrary  to 
the  statements  of  some.  In  one  case 
there  was  a  retention  of  the  albumin 
metabolism  and  in  the  other  a  loss.  Di- 
gestive functions  were  good.  Acidity  of 
the  urine  was  high.  The  elimination  of 
PjOj  in  the  faices  was  normal.  In  the 
urine  there  was  a  retention  on  the  part 
of  the  man  and  a  loss  of  P,,0|,  on  that 
of  the  girl.  G.  Vannini  (Berliner  klin. 
Woch.,  July  10,  1900). 

In  a  certain  number  of  cases  the  poly- 
uria is  referable  to  a  traumatic  cause; 
for  instance,  a  fall  upon  the  head.  Some- 
times diabetes  mellitus  immediately  fol- 


lows the  traumatism  and  it  is  only  after 
a  time,  two  months  or  more,  that  it 
changes  to  diabetes  insipidus.  There  is, 
consequently,  an  imdoubted  connection 
between  the  two  affections.  This  has 
likewise  been  proved  by  experimenta- 
tion. Claude  Bernard,  in  puncturing  a 
certain  spot  in  the  floor  of  the  fourth 
ventricle  in  a  rabbit,  caused  diabetes 
mellitus,  while  in  puncturing  at  a 
slightly  different  point,  he  caused  sim- 
ple polyuria. 

After  traumatism  of  the  cranium  the 
chronic  lesions  of  the  encephalon,  and 
tumors,  in  particular,  occupy  an  impor- 
tant place  in  the  etiology  of  polyuria. 
I  have  seen  several  cases  of  this  kind. 
In  one  of  them  there  was  found  at  the 
autopsy  a  tumor  of  the  optic  thalamus. 
The  polyuria  appeared  very  suddenly. 

Syphilitic  lesions  of  the  encephalon 
are  the  principal  causes  of  polyuria.  The 
number  of  such  cases  is  very  great. 

Finally,  simple  neuroses  frequently 
bear  a  relation  to  this  affection. 

As  already  pointed  out  by  the  writer, 
the  suprarenal  gland  contains  a  sub- 
stance which  gives  rise  to  glycosuria  if 
brought  into  the  circulation  in  minute 
doses.  This  substance  is  identical  with 
that  constituent  of  the  suprarenal  which 
turns  solutions  of  iron  green  and  re- 
duces ammoniacal  solution  of  silver,  and 
which  also  serves  to  increase  blood- 
pressure.  Suprarenin  and  adrenalin 
possess  this  sugar-producing  power.  A 
fraction  of  a  milligramme  of  this  sub- 
stance, or  the  contents  of  a  single  su- 
prarenal gland,  serves  to  give  rise  in 
a  rabbit  to  nearly  0  per  cent,  of  dex- 
trose in  tlie  urine.  In  dogs  fed  exclu- 
sively on  meat,  4  per  cent,  of  grape- 
sugar  was  found  in  the  urine.  The  gly- 
cosuria persisted  for  two  and  three 
days.  By  continued  injections  of  supra- 
renal juice  true  diabetes  may  be  pro- 
duced. The  starting-point  of  the  sugar- 
producing  agent  of  the  suprarenals  the 
writer  believes  to  be  in  the  liver.  Hun- 
gry dogs  whose  glycosuric  power  may  be 


DIABETES  INSIPIDUS. 


DIABETES  MELLITUS. 


427 


regarded  as  exhausted  excrete  scarcely 
any  dextrose  after  injections,  but  if  fed 
on  fat  they  begin  again  to  give  off 
dextrose  in  large  quantity.  There  is  a 
great  probability  that  the  suprarenals 
have  etiological  relation  to  many  forms 
of  human  diabetes;  especially  Addison's 
disease  may  be  due  to  loss  of  activity 
in  the  suprarenals.  F.  Blum  (Amer. 
Medicine,  May  31,  1902). 

Pathology. — As  to  the  pathogenesis,  it 
is  not  unlikely  that  primary  polyuria — 
not  polydipsia — is  caused  by  paralysis  of 
the  vasoconstrictors  of  the  kidney.  It  is 
difficult  to  conceive  of  a  permanent  ex- 
citation of  the  vasodilators.  There  may 
likewise  be  a  defect  in  the  normal  re- 
sorption of  the  water,  which,  as  we  know, 
takes  place  in  the  normal  condition  in 
the  tubules;  but  this  mechanism  appears 
rather  to  be  that  of  the  polyuria  attend- 
ing interstitial  nephritis.  The  health  is 
'naturally  much  less  affected  in  polyuria 
than  in  diabetes  mellitus;  but  in  true 
polyuria  the  defective  hydration  of  the 
tissues  is  likely  to  cause  certain  nervous 
troubles,  which  in  themselves  are  of  no 
very  great  importance. 

Treatment. — In  neuropathic  subjects 
the  general  condition  should  be  treated 
by  means  of  bromide  of  potassium,  vale- 
rian, etc.  For  the  special  treatment  of 
the  polyuria  ergot  of  rj'c  (or,  even  better, 
ergotine)  and  antipyrine  should  be  used. 
The  above  two  remedies,  the  first- 
named,  in  particular,  have  cured  the  dis- 
ease. I  have  also  obtained  some  success 
by  the  use  of  the  continuous  current,  the 
positive  pole  being  placed  upon  the 
spinal  column,  and  the  negative  at  the 
level  of  the  hilum  of  the  kidney. 

Case  in  a  man  of  40  years,  who  de- 
veloped diabetes  after  a  fall  which  re- 
sulted in  a  severe  shock  to  the  nervous 
system.  The  writer  tried  various  meth- 
ods of  treatment  without  success,  until 
he  began  the  injection  of  strychnine,  as 
recommended  by  Feilchenfeld.  The  ni- 
trate was  given  in  daily  quantities  of 


from  0.002.5  to  0.00.5  giamme  for  20 
days.  The  urine,  which  had  amounted 
to  SOOO  c.  c,  continued  to  steadily  de- 
crease in  amount.  The  drug  had  to  be 
stopped  at  the  end  of  twenty  days,  on 
account  of  the  symptoms  of  into.xica- 
tion,  but  the  urine  continued  to  de- 
crease in  amount  down  to  2400  c.  c. 
The  patient's  general  condition  also  im- 
proved and  at  the  end  of  four  weeks 
the  urine  was  about  2000  c.  c.  daily 
and  the  man  was  practically  cured.  Xo 
explanation  of  the  action  of  the  drug  in 
this  case  is  offered.  B.  Leiek  (Deutsche 
med.  Wochen.,  Aug.  11,  1904). 
If  the   polyuria  is   dependent   upon 

nervous  lesions,  the  same  means  are  to 

be  employed. 

R.  Lei'i.ve, 

Lyons. 

DIABETES  MELIITUS. 
Deinition. — A    malady    characterized 
by  non-accidental — that  is  to  say,  a  per- 
manent or  very  nearly  permanent — gly- 
cosuxia. 

Symptoms. — With  but  rare  exceptions, 
the  onset  of  this  disease  is  insidious,  and 
cannot  be  recognized  by  the  patient. 
Many  cases  of  diabetes  remain  entirely 
unsuspected  until  the  time  when  some 
symptom  other  than  the  glycosuria  at- 
tracts the  attention  of  the  patient.  This 
may  be  either  excessive  thirst,  poly- 
uria, unusual  wealcness,  or  even  im- 
potence. More  rarely,  it  is  a  sudden 
diminution  of  the  acuity  of  the  vision, 
or  perhaps  a  complication  in  the  form 
of  anthrax  or  balanitis  in  men,  and  pru- 
ritus vulvte  in  women.  The  daily  quan- 
tity of  urine  is  increased,  except  in  some 
rare  eases,  classed  under  the  head  of 
"diabetes  decipieiis." 

Initial  symptoms  of  diabetes  mellitus 
in  children  are  apt  to  be  incontinence 
of  urine,  nervous  irritability,  and  great 
thirst.  Strength,  llcsh.  and  color  may 
sometimes  be  retained  until  nearly  the 
end.  A  gain  of  weight  and  height,  even, 
may  occur,  without  any  amelioration  of 


428 


DIABETES  MELLITUS.    SYMPTOMS. 


the  disease.  Townsend  (Boston  Med.  and 
Surg.  Jour.,  May  11,  '99). 

Pruritus  -v-uIveb  Is  the  initial  symptom 
of  diabetes  in  about  20  per  cent,  of  the 
cases.  Premature  menopause  is  rela- 
tively common  in  diabetics.  Danck- 
worth  (Centralb.  f.  Gynlik.,  No.  23,  '99). 

In  350  cases  219  complained  solely  of 
polydipsia  as  the  first  sign  of  diabetes. 
Lassitude,  neuralgia,  insomnia,  neuras- 
thenia, and  syncope  were,  in  the  order 
named,  the  principal  symptoms.  M.  E. 
Dufourt  (La  Presse  M6d.,  June  2,  1900). 

The  urine  is  pale  in  color,  the  reac- 
tion is  sometimes  unmistakably  acid; 
the  specific  gravitj",  except  in  some  very 
rare  cases,  is  very  perceptibly  increased 
(1025  to  1045  and  even  1050  has  been 
met  with).  The  odor  is  sweet,  owing  to 
the  presence  of  glucose,  which  may 
amount  to,  or  even  exceed,  8  per  cent. 
Generally  speaking,  the  quantity  as 
given  by  Fehling's  test  is  a  little  more 
than  that  registered  by  the  polarimeter. 
This  is  due,  first,  to  the  fact  that  the 
urine  contains  reducing  substances  which 
are  not  deviated  by  polarized  light,  and, 
second,  to  the  fact  that  in  a  number  of 
cases  of  severe  diabetes  beta-oxybutyric- 
acid  salts  are  present  in  the  urine,  which 
deviate  to  the  left  in  such  a  manner 
that  a  portion  of  the  deviation  of  the 
glucose  to  the  right  is  thus  masked. 

In  mild  cases  of  diabetes  the  true 
beta-oxybutric  acid  is  not  present  in  the 
urine;  there  may,  however,  be  other 
substances  which  deviate  to  the  left, 
especially  levulose,  which  has  occasion- 
ally been  met  with  in  diabetes,  to  the 
exclusion  of  the  glucose  (Zimmer,  Kiilz, 
Seegen,  Marie). 

Other  sugars  have  sometimes  been 
found;  for  instance,  traces  of  pentose 
(>SalkowBki,  Kiilz),  inosite,  etc. 

A  mixture  of  dextrosazone  and  pen- 
toHazone  found  in  the  urine  of  76  out  of 
80  caBea  of  diabetes.  In  04  reaction  posi- 
tive,   in    remaining    12    cases    doubtful. 


Kulz  and  Togel   (Zeit.  f.  Biol,  B.  32,  p. 
185,  '95). 

In  12  cases  of  diabetes  the  excretion 
of  calcium  salts  was  considerably  in- 
creased in  the  severe  forms  of  diabetes, 
while  in  mild  forms  the  excretion  was 
the  same,  or  only  a  little  in  excess  of 
that  met  with  in  the  urine  of  healthy 
persons.  This  increased  lime  excretion 
is  due  to  the  greater  amount  of  food  and 
water  taken,  especially  to  the  increased 
amount  of  nitrogenous  food.  In  those 
cases  in  which  very  large  quantities  of 
lime  salts  are  excreted  (1  to  1  Vs  grains 
of  calcium  oxide)  in  the  twenty-four 
hours,  the  destruction  of  the  albumin 
of  the  body  is  playing  some  part  in  the 
production  of  this  condition.  E.  Ten- 
baum  (Zeit.  f.  Biol.,  pp.  379-403,  '96). 

Several  important  chemical  substances 
are   found   in   diabetic   urine.     Next   to 
sugar,  those  having  the  gi-eatest  signifi- 
cance   are    acetone,    diacetic    acid,    and 
oxj'butyric  acid.     E.  L.  Munson    (Jour. 
Amer.  Med.  Assoc,  May  1   to  22,  June 
1,  '97). 
Albuminuria  exists  in  diabetes,  in  at 
least  one-third  of  the  cases,  but  in  only 
a  few  cases  is  it  symptomatic  of  Bright's 
disease. 

One  of  the  most  common  complications 
of  diabetes  mellitus  is  an  albuminuria, 
doubtless  in  most  instances  secondary  to 
the  action  of  a  urine  rendered  irritant 
by  the  presence  of  sugar  upon  the  renal 
structures.  In  1300  diabetics  in  whose 
urine  the  condition  was  sought  for,  824 
were  also  subjects  of  an  albuminuria. 
In  a  large  number  of  these  cases  the 
cause  of  the  albuminuria  is  probably  the 
excessive  amount  of  eggs  consumed  in 
the  diabetic  diet,  while  in  others  the 
albuminuria  is  symptomatic  of  some 
complication,  as  tuberculosis,  cardiac 
disease,  renal  inflammation,  or  a  cystitis 
or  pyelitis,  depending  upon  the  irritating 
nature  of  the  sugary  urine.  Schmitz 
(Berliner  klin.  Woch.,  Apr.  13,  '91). 

in  pancreatic  diabetes  albuminuria  is 
quite  exceptional;  in  traumatic  diabetes 
it  is  a  little  more  frequent;  albuminuria 
is  by  far  most  frequently  met  with  in 
diabetes  with  obesity.  In  grave  form 
of  albuminuria  of  diabetes  well-marked 


DIABETES  jVIELLlTUS.    SYMPTOMS. 


429 


nephritis  is  always  found  at  autopsy; 
in  the  benign  form  but  slight  nephritic 
changes  are  sometimes  found;  more 
rarely  no  changes  are  detected  in  the 
kidneys.  Replacement  of  sugar  by  albu- 
min is  always  an  extremely  grave  sign, 
but  the  case  may  not  immediately  termi- 
nate fatally.  Jacobson  (Gaz.  des  HOp., 
Aug.  25,  '94). 

Analysis  of  17  cases  showing  that  al- 
buminuria  in   connection   with   diabetes 
may  exist  for  a  long  time  without  lead- 
ing to  any  sj-mptoraatic  indication  of  its 
presence.    It   is,   therefore,   less   signifi- 
cant  in    these   cases    than    in    ordinary 
conditions  of  nephritis,  making  it  evi- 
dent that  albumin  and  casts  have  a  dif- 
ferent   signification    according    to    the 
conditions    with   which   thej'   are   asso- 
ciated.    Experience    shows     that,    even 
apart  from  diabetes,  they  are  met  with 
frequently  in  persons  of  advanced  age 
who    present    no    other    symptoms    of 
renal  trouble.    That  they  are  insignifi- 
cant is   often   shown   by   the   fact  that 
time  may  pass  without  the  development 
of     further     symptoms.     F.     W.     Pavy 
(Lancet,  Dec.  5,  1903). 
Owing  to  the  polyuria,  urea  is  nat- 
urally only  present  in  the  urine  in  a 
very   small   propori;ion,   but  the   daily 
quantity  of  this  substance  is  increased. 
Its  relation  to  the  total  of  nitrogen  is 
not  noticeably  altered,  except  in  grave 
cases  of  diabetes,  in  which  the  propor- 
tion of  ammoniacal  salts  is,  as  is  well 
known,  greatly  increased,  in  order  to 
overcome  the  acid  dyscrasia. 

In  serious  cases  the  excretion  of  lime 
is  also  increased.  Thirst  is  usually,  but 
not  always,  predominant.  Hunger  is 
much  less  frequent,  and  a  great  many 
diabetic  patients  do  not  eat  any  more 
than  a  healthy  person.  Constipation  is 
the  rule,  being  either  due  solely  to  the 
impoverishment  of  the  system  with  re- 
gard to  water,  or  to  an  exaggerated  tonus 
of  the  splanchnic  nerre.  It  may  be 
stated,  in  support  of  the  latter  hy- 
pothesis, that  this  symptom  frequently 
precedes  the  appearance  of  the  diabetes. 


The  saliva  is  more  abundant.  Ex- 
ceptionally it  has  been  found  to  con- 
tain sugar  and  sometimes  lactic  acid. 
The  skin  is  dry  and  perspiration  is 
rarely  modified  from  the  normal.  The 
blood  contains  a  variable  proportion  of 
glucose,  usually  more  than  3  grammes 
per  litre,  and  quite  frequently  from  4 
to  5  grammes.  In  exceptional  cases, 
when  the  Iddneys  have  undergone  altera- 
tion, the  proportion  may  be  greater. 

[I  have  recently  seen  a  case  in  which 
there  were  more  than  10  grammes  of 
sugar  per  litre.     K.  LiipiKE.  ] 

There  is  no  close  relation  between  the 
percentage  of  sugar  in  the  blood  and 
urine.  That  more  sugar  is  excreted  by 
the  urine  on  certain  days  than  on  others 
does  not  depend  on  the  fact  that  the 
amount  in  the  blood  has  reached  a  cer- 
tain quantity,  but  on  other  complex 
conditions.  The  administration  of  a 
diuretic  diminishes  hyperglycsEmia  and 
retards  the  decrease  of  glycosuria.  Lu- 
pine  (Lyon  Med.,  July  21,  '95). 

When  treated  by  certain  aniline  colors, 
the  red  globules  (as  found  by  Bremer) 
take  on  a  different  color  in  diabetic  pa- 
tients from  that  assumed  in  other  pa- 
tients or  in  healthy  subjects. 

The  pulse  is  full,  but  of  normal  fre- 
quency, except  in  the  case  of  complica- 
tions, when  it  may  be  rapid. 

The  majority  of  diabetics  excrete  more 
nitrogen  than  healthy  persons  of  the 
same  weight.  This  results  from  the  fact 
that  the  sugar  not  being  completely 
utilized,  they  must  necessarily  consume 
more  albuminoid  matter  (and  fatty  sub- 
stances), as  has  been  proved  by  com- 
parative experiments  made  upon  a  dia- 
betic patient  and  a  healthy  subject. 

[Pettenkofcr  and  Voit  formerly  be- 
lieved that  diabetics  absorbed  less  oxy- 
gen and  excreted  less  carbonic  acid  than 
healthy  subjects.  Later  on  Voit  formu- 
lated certain  reservations  upon  this  sub- 
ject, and  Leo,  in  an  important  article, 
affirmed  that,  with  an  equal  weight  in 


430 


DIABETES  MELLITUS.    SYMPTOMS 


the  diabetic  and  the  healthy  person,  the 
respiratory  exchanges  are  the  same. 
This  opinion  has  again  been  contradicted. 
K.  Lepine.] 

Twenty  experiments  upon  5  diabetics, 
two  having  a  grave  form  of  the  disease, 
which  prove  that  the  absorption  of  oxy- 
gen and  the  exhalation  of  cjirbonio  acid 
are  not  diminished  in  diabetics,  if  their 
weight  is  considered.  The  following  are 
the  figures  obtained  by  causing  the  pa- 
tients to  breathe  for  several  minutes 
into  the  apparatus  of  Zuntz  and  Gep- 
pert,  the  volume  of  gas  being  calculated 
by  minutes  and  the  kilogrammes  by 
■weight: — 

CO..         O.  Quotieut. 
First  patient  (grave),      .        .    3.L'1  4.01  SO.O 

Second  patient  (mild),    .       .    2.83  3.S7  74.4 

Third  patient  (mild).      .       .    3.21  2.84  81.0 

Foarth  patient  (mild),    .        .     2.30  3.4S  SO.O 

Fifth  patient  (very  grave),     .    2.64  4.27  60. J 

Hans  Leo  (Zeit.  f.  klin.  Med.,  B.  19, 
'92). 

Hanriot,  Weintraub  and  Laver,  Eb- 
stein,  and  others  positively  assert  that, 
when  subjected  to  the  same  regime  dia- 
betics e.xhale  less  carbonic  acid  than 
healthy  persons. 

The  diminished  CO;  is  the  result,  not 
the  cause,  of  the  diabetic  condition; 
there  is  less  CO;  because  there  is  less 
combustion  of  glycogen.  Arnold  Cantani 
(Deut.  raed.  Woch,,  Nos.  12  to  14,  '89). 

The  diminished  elimination  of  CO2, 
which  is  characteristic  of  diabetes,  ia  the 
cause  of  the  large  sugar  production,  be- 
cause in  healtli  the  action  of  the  dias- 
tatic  ferment  upon  glycogen  is  held  in 
check  by  COj,    Ebstein  (Annual,  '90). 

Estimations  of  the  carbon  dioxide  in 
the  blood  and  its  alkalinity  in  23  sam- 
ples of  blood  from  15  patients,  8  being 
cases  of  diabetic  coma,  3  of  diabetes 
without  coma,  and  4  being  from  eases 
of  oedema  of  tlie  lung,  pancreatic  dis- 
ease, pernicious  antemia,  and  ascites,  re- 
spectively. In  all  tlie  cases  of  diabetic 
coma  tlie  quantity  of  carbon  dioxide 
was  one-lialf,  or  less  than  one-half,  the 
normal,  and  in  the  blood  of  the  non- 
comatoHe  there  was  also  less  COj  than 
in  normal  blood,  but  more  than  in 
comatose  patients.  In  (lif  iliiilK'tif: 
cases,   diacetic   acid   ami    Mutonc    were 


present  in  the  urine.  In  2  cases  they 
found  that  the  amount  of  total  nitro- 
gen excreted  as  IVH3  was  high.  The 
writers  did  not  lind  the  amount  of  gas 
in  the  urine  in  diabetes  to  be  above  the 
normal.  Tliese  experiments  and  others 
in  progress  indicate  that  in  diabetic 
coma  the  respiratory  symptoms  are  not 
entirely  to  be  explained  by  the  assump- 
tion of  a  chemical  disability  of  the 
blood  to  combine  with  carbon  dioxide. 
Beddard,  Pembrey,  and  Spriggs  (Lan- 
cet, May  le,  1903). 

'When  a  diabetic  subject  has  been 
made  to  absorb  a  large  proportion  of 
starchy  matter  or  sugar,  the  difference 
in  the  respiratory  exchange  between  the 
diabetic  and  the  healthy  subject  becomes 
particularly  evident.  The  healthy  per- 
son, soon  after  this  ingestion,  exhales  a 
large  amount  of  carbonic  acid;  in  the 
diabetic  there  are  no  very  noticeable 
modifications.  This  important  fact, 
added  to  many  others,  proves  that  the 
diabetic  is  incapable  of  utilizing  the 
carbohydrates  as  effectively  as  a  healthy 
subject. 

Views  based  upon  experience  with 
1004  cases.  In  diabetes  mellitus  we  have 
a  non-combustion  of  carbohydrates, 
whether  introduced  from  without  or  pro- 
duced within  the  organism.  The  fact 
that  the  ingestion  of  sugar  is  always 
followed  by  its  appearance  in  tlie  urine 
at  a  very  short  interval  disposes  of  all 
theories  which  make  diabetes  the  result 
of  increased  sugar-production  in  the 
tissues.  Diabetes  consists,  in  the  first 
place,  in  the  non-combustion  of  some 
part  of  the  carbohydrates,  the  excess  of 
non-assimilated  sugar  a])])caring  in  the 
urine.  As  the  disease  progresses,  a 
smaller  and  smaller  amount  is  burned, 
until  none  is  oxidized,  Arnold  Cantani 
(Deut.  med.  Woch.,  Nos,  12  to  14,  '89). 
Nearly  all  cases  of  diabetes  show  fluct- 
uations in  the  twenty-four  hours.  Gen- 
erally diabetics  cannot  assimilate  the  car- 
bohydrates which  are  taken  for  break- 
fast on  an  empty  stomach,  but  they  may 
assimilate  these  substances  if  taken  for 
luncheon  or  dinner.    There  is  prognostic 


DIABETES  MELLITUS.     SYMPTOilS. 


431 


value  in  the  fluctuations  which  occur  in 
the  elimination  of  sugar;  if  these  are 
regular,  they  indicate  a  mild  case;  if 
they  are  not  marked  and  are  irregular, 
the  case  is  relatively  severe.  F.  Fred- 
erick Grouse,  Jr.  (Albany  Med.  Annals, 
Aug.,  '99). 

General  Symptomatology. — I  shall 
successively  take  up  (1)  those  of  the 
nervous  system,  (2)  those  of  the  vascu- 
lar system,  (3)  those  of  the  respiratory 
tract,  (4)  the  digestive  apparatus,  (5) 
the  urinary  tract,  and  (6)  the  sMn  and 
the  locomotor  apparatus,  ending  with  a 
summary  statement  concerning  the  dia- 
betic coma. 

Nervous  System. — The  most  common 
secondary  nervous  lesions  of  diabetes  are 
certain  peripheral  neuroses,  especially 
those  which  cause  the  abolition  of  the 
knee-jerk. 

The  condition  of  the  knee-jerk  tested 
in  184  cases  of  diabetes  mellitus.  As 
only  1  examination  was  made  in  56  of 
the  cases,  they  are  excluded  from  con- 
sideration. Of  the  128  remaining  cases, 
the  knee-jerk  was  normal  in  113  and 
increased  in  2.  In  the  latter  cases  the 
patients  were  suffering  from  a  severe 
form  of  diabetes.  In  4  cases  of  severe 
diabetes  the  knee-jerk  was  absent  or 
greatly  diminished.  The  phenomenon 
was  absent  in  9  slight  cases.  Excluding 
3  of  these, — because  2  of  the  patients 
were  tabetic  and  the  third  was  too 
obese  to  admit  of  satisfactory  examina- 
tion,— there  were  only  10  patients  (7.6 
per  cent.)  in  whom  the  knee-jerk  was 
abolished  or  much  reduced.  Grube  (Bull, 
de  la  Soc.  Anat.,  Nov.  1.5,  '93). 

Analysis  of  50  cases  of  diabetes  with 
relation  to  the  knee-jerks.  They  were 
both  absent  in  50  per  cent.,  both  pres- 
ent in  38  per  cent.,  and  feeble  or  one 
absent  in  12  per  cent.  In  patients  under 
25  years  the  knee-jerks  were  absent  in 
80  per  cent.;  under  30  years,  absent  in 
75  per  cent.;  over  30  years,  absent  in 
46  per  cent.  R.  T.  Williamson  (Med. 
Chronicle,  No.  2,  '93). 

Three  hundred  and  thirty-two  cases  of 
diabetes  mellitus  in  which  the  knee-jerk 


was  tested.  The  knee-jerk  was  lost  in 
49  per  cent,  of  the  cases  of  slight  diabetes 
and  but  24  per  cent,  of  the  severe  cases. 
In  11  cases  there  was  neuritis  on  both 
sides,  no  cause  but  diabetes  being  pres- 
ent, e.xcept  possibly  alcohol  in  2  cases. 
Three  manifestations  of  nervous  disturb- 
ance were  caused  by  increase  of  sugar  in 
the  blood:  (1)  cramps,  or  an  acute  irri- 
tation of  nerves;  (2)  neuritis,  or  acute 
inflammation  of  the  nerves;  (3)  a  slow 
degeneration,  or  nutritive  change,  in  the 
nerves,  seeming  to  have  a  preference  for 
the  crural  nerve,  and  thus  causing  loss 
of  knee-jerk.  Grube  (Lancet,  July  22, 
'90). 

The  other  neurotic  symptoms  are  pain 
and,  more  rarely,  paralysis.  It  has  been 
known  for  a  long  time  that  the  neuralgia 
of  diabetes  is  very  painful  and  difficult 
to  cure.  Worms  has  noted  that  it  is 
very  often  symmetrical,  and  states  that 
the  pain  increases  and  decreases  with  the 
hyperglycemia,  which  is  certainly  in- 
constant. Ziemssen  was  the  first  to  refer 
this  neuralgia  to  a  neuritis.  There  are 
also  shooting  pains  that  somewhat  re- 
semble those  of  ataxia,  and  which  may, 
in  some  cases,  suggest  the  question  as 
to  whether  there  is  not  actual  tabes:  a 
very  difficult  problem  to  decide. 

Vergely  reported  a  case  in  which  there 
were  pains  resembling  those  of  angina 
pectoris. 

The  paralyses  of  diabetes  present 
themselves  as  follows:  1.  Limited  and 
incomplete  paralysis;  this  is,  by  far,  the 
most  prevalent  form,  as  has  been  stated 
by  Bernard  and  Fer6  in  ISS-i.  2.  Mon- 
oplegia. 3.  Hemiplegia.  4.  Para- 
plegia. The  various  forms  of  diabetic 
paralysis  are  sometimes  associated,  or  are 
combined,  with  some  unusual  phenom- 
ena; for  instance,  facial  hemiplegia  pre- 
ceded by  facial  neuralgia  and  a  falling  of 
the  upper  eyelid  (Charcot,  quoted  by 
Bernard  and  F6r6),  or  paresis  of  the  ex- 
tensors of  the  left  thigh,  impeded  speech, 


132 


DIABETES  MELLITUS.    SYMPTOMS. 


and  deviation  of  the  mouth  to  the  left 
(Charcot,  ibid.),  etc.  The  progress  of 
these  paralyses  is  also  somewhat  pecul- 
iar: the}'  are  sometimes  migratory  and 
transitory.  Some  of  them  are  undoubt- 
edly of  central  origin,,  but  the  majority 
are  of  peripheral  origin,  a  neuritis  form- 
ing their  anatomical  substratum.  The 
peripheral  variety  is  not  exempt  from 
this  rule,  as  is  proved  by  the  existence, 
in  diabetic  paraplegia,  of  the  symptom- 
complex  which  Charcot  has  given  the 
name  of  steppage,  which  is  characterized 
by  the  lowering  of  the  forward  part  of 
the  foot  in  walking.  This  we  know  is 
due  to  the  paralysis  of  the  extensors  of 
the  foot,  and  it  occurs  in  peripheral 
neuritis,  but  not  in  myelitis. 

Cramps  are  another  motor  disturbance 
met  with  in  diabetic  subjects.  These 
occur  principally  in  the  lower  extremi- 
ties, and  at  night  they  give  rise  to  in- 
somnia, which,  according  to  Bernard 
and  Fere,  appears  to  be,  in  diabetic  sub- 
jects, the  first  symptom  of  disturbance 
of  the  cerebral  circulation,  and  may 
sometimes  prove  to  be  the  forerunner  of 
serious  symptoms. 

Frequency  of  cramps  in  the  calves  in 
diabetics.  Disease  frequently  begins  in 
form  of  an  obstinate  gastric  catarrh ;  ex- 
amination of  urine  for  sugar  in  all  pa- 
tients sufTering  from  rebellious  catarrh 
of  stomach,  recurring  in  spite  of  all  treat- 
ment, desirable.  Jacobson  (Brooklyn 
Med.  Jour.,  Nov.,  '94). 

[Convulsions  arc  rare.  Some  time  ago 
I  reported  a  case  in  which  they,  as  well 
as  aphasia  and  hemiplegia,  depended 
upon  microscopical  cortical  lesions.  R. 
Llil'INE.] 

The  complication  of  ajihaHia  may  occur 
in  cither  pronounced  or  latent  cases  of 
diabetes,  and  may  be  associated  with  ob- 
stinate neuralgia,  disturbance  of  vision, 
headache,  or  impairment  of  hearing. 
The  apliasia  may  occur  at  any  period  in 
the  course  of  the  disease,  and  may  last 
from  a  few  hours  to  a  month  or  more. 


The  prognosis  is  always  good.  The  con- 
dition can  be  said  to  resemble  very 
closely  the  various  forms  of  toxic  aphasia 
that  attend  ursemia,  pneumonia,  gout, 
and  tobacco-poisoning.  Corneille  (Gaz. 
Hebd.  de  Med.  et  de  Chir.,  Jan.  20,  '9S). 

Perforating  ulcer  sometimes  compli- 
cates diabetes.  Folet  and  Auche  have 
observed  the  falling  ofE  of  the  nails.  In 
Folet's  case  they  fell  without  giving  rise 
to  pain  or  inflammation. 

Case  of  diabetes  in  an  infant  4  to  5 
months  old.  The  urine  contained  large 
quantities  of  sugar.  Polyuria,  poly- 
phagia, autophagia,  and  boils  were  pres- 
ent. At  autopsy  there  was  found  acute 
broncho-pneumonia  with  pulmonary 
oedema,  acute  intestinal  catarrh,  oedema 
of  the  dura,  and  a  serous  effusion  in  the 
third  ventricle.  N.  A.  Orlow  (Vratch, 
Mar.  3,  1901). 

Organs  of  Special  Sense. — Cataract  is 
the  most  common  symptom;  it  nearly 
always  develops  in  both  eyes;  if  not 
simultaneously,  at  least  after  a  short 
interval.  It  is  characteristic  of  this 
form  of  cataract  to  be  relatively  soft. 
Eetinitis  is  next  in  order,  with  white 
exudations  along  the  vessels  and  in  the 
perimacular  region. 

Many  causes  may  lead  to  ocular  le- 
sions in  this  disease.  Among  them  are 
(1)  diminution  of  water;  (2)  diminu- 
tion of  resistance  of  the  vessels,  due  to 
general  weakening  of  nutrition;  (3)  the 
existence  of  a  toxic  substance  in  the 
blood,  produced  by  abnormal  processes; 
(4)  various  complications.  Mauthner 
(Inter,  klin.  Rund.,  No.  2.5,  '93). 

From  a  study  of  2.'5  cases  in  which 
lesions  of  various  character  were  found 
in  association  with  diabetes,  three  groups 
are  distinguished:  (1)  a  characteristic 
inflammation  of  the  central  region  of 
tlic  retina,  with  small,  bright  areas,  and 
frequently,  also,  small  hnemorrhages;  (2) 
retinal  hemorrhages,  with  the  conse- 
quent inflammatory  and  degenerative 
changes;  (3)  rarer  varieties  of  retinitis 
and  degeneration,  the  relation  of  which 
to  the  constitutional  disease  remains  to 


DIABETES  MELLITUS.    SYMPTOMS. 


433 


be     demonstrated.       Hirschberg     (Deut. 
med.  Woch.,  Dec.  18,  25,  '90). 

This  form  is  nearly  always  accom- 
panied by  slight  hjEinorrhages.  True 
optic  neuritis  is  much  more  rare. 

The  retinitis  of  diabetes  distinguished 
from  that  of  Bright's  disease  as  follows: 
1.  The  patches  are  irregularly  distrib- 
uted around  the  centre  of  the  retina, 
not  specially  near  the  macula,  and  are 
met  with  on  the  nasal  as  well  as  on  the 
temporal  side  of  the  disk.  2.  The  patches 
are  never  arranged  in  a  fan  shape.  3. 
They  are  never  associated  with  papillitis 
or  diffuse  retinitis.  4.  The  h.iemorrhages 
are,  as  a  rule,  punctiforni,  and  not 
striated.  5.  Hfemorrhages  into  the  vitre- 
ous are  common.  Saundby  (Birming- 
.   ham  Med.  Rev.,  Jan.,  Feb.,  '93). 

Out  of  140  diabetics,  34  were  found 
who  were  the  subjects  of  retrobulbar 
neuritis,  which  could  not  be  attributed 
to  abuse  of  alcohol  or  tobacco.  Schmidt- 
Einipler  (Annal.  d'Oculist.,  Sept.,  '96). 

Unusual  case  of  neuroretinitis  where 
the  changes  were  very  characteristic  of 
albuminuric  retinitis,  with  two  excep- 
tions, namely:  the  star-shaped  figure 
that  is  commonly  seen  at  the  macula  in 
albuminuric  retinitis  was  found  below 
and  to  the  nasal  side  of  the  disk,  and 
the  papilla  was  swelled  more  than  is 
usually  found  in  the  albuminuric  form. 
The  round,  white  patches,  the  numerous 
small  and  flame-shaped  hsEUiorrhages, 
and  the  oedema  were  found.  Lens  and 
vitreous  were  clear.  Vision  equaled  '"/n- 
The  man  complained  only  of  decreasing 
vision. 

The  urine  was  repeatedly  examined, 
but  showed  no  trace  of  albumin  or  sugar. 
It  was  abnormally  abundant,  very  rich 
in  phospliates,  and  of  normal  specific 
gravity.  At  first  he  passed  seventy-nine 
ounces  daily.  Hansell  (Phila.  Poly- 
clinic, Jan.  30,  '97). 

This  condition  would  e.xplain  the  ex- 
istence of  the  central  scotoma  sometimes 
met  with  in  diabetes. 

Case  of  diabetic  neuritis  with  central 
scotoma.  At  autopsy  zone  of  degenera- 
tion in  optic  nerve.  Eraser  and  Bruce 
(Edinburgh  Med.  Jour.,  May,  'O.'i). 


Besides  the  ocular  lesions  mentioned, 
Panas,  and,  after  him,  Hirschberg,  have 
insisted  upon  visual  disturbances  caused 
by  a  defect  of  accommodation. 

Out  of  717G  eye-patients,  113,  or  1'/, 
per  cent.,  were  diabetics.  After  ten 
years'  existence  this  disease  regularly 
causes  alterations  of  the  eye-structures, 
particularly  of  the  lens  and  retina.  In 
a  third  of  the  cases  diabetes  was  found 
associated  with  some  of  the  following 
significant  changes:  (1)  uncomplicated 
paralysis  of  accommodation  in  middle 
life;  (2)  late  myopia  occurring  between 
40  and  CO  years,  without  changes  in  the 
lens;  (3)  retinitis;  and  (4)  quickly  de- 
veloped cataract  in  young  persons  in 
poor  health.  Hirschberg  (Deut.  med. 
Woch.,  Mar.  20,  '91). 

There  may  be  functional  ocular  dis- 
turbances with  diabetes,  either  of  ac- 
commodation>  refraction,  or  visual 
acuity.  It  may  be  paralysis  of  accom- 
modation, yet  it  is  always  partial,  prob- 
ably toxic  in  origin.  Myopia  is  not  un- 
common, or  cataract,  or  diminished  re- 
fraction; or  there  may  be  disturbed 
central  or  peripheral  vision,  amblyopia, 
hemianopsia,  etc.  Separate  muscles 
may  be  paralyzed;  there  may  be  diplo- 
pia. F.  Terrien  (Jour,  des  Prat.,  Feb. 
14,  1903). 

Paralysis  of  the  intrinsic  muscles  is 
very  rare.  Paresis  of  the  abducens  some- 
times occurs;  also  a  combined  paralysis 
of  the  motor  oculi,  which  gives  rise  to 
imperfect  lateral  motion  of  both  eyes. 
A  nuclear  origin  is  evident  in  these 
cases. 

Gell6  states  that  suppuration  of  the 
ear  is  not  rare  in  diabetics.  The  progress 
of  acute  otitis  is  the  same  as  that  ob- 
served in  gout:  rapid  tumefaction,  pro- 
trusion, and  redness  of  the  tympanum. 
During  the  second  day  severe  pain,  and 
afterward  abundant  suppuration. 

Inflammation  of  the  mastoid  is  very 
frequent    in    diabetes    mellitus.      R.    A. 
Urquhart  (Med.  News,  Mar.  21,  '90). 
Two  cases  of  acute  mastoiditis  in  per- 


434 


DIABETES  MELLITUS.    SYMPTOMS. 


sons  suffering  from  diabetes  mellitus. 
In  the  first  case,  the  patient,  a  woman 
aged  50,  induced  the  acute  ear  inflam- 
mation as  the  result  of  snuffing  salt- 
water up  the  nose.  At  first  she  made 
good  progress  under  treatinent.  Soon, 
however,  began  to  complain  of  consid- 
erable pain  in  the  right  half  of  the  head, 
with  continued  discharge,  renewed  pul- 
sating tinnitus,  and  commencing  mastoid 
tenderness,  until  it  became  requisite  to 
open  the  mastoid  process.  The  interior 
of  the  process  was  found  made  up  of 
small  cells,  in  many  of  which  were  un- 
healthy granulations. 

In  the  second  ease,  the  patient,  a  man 
aged  58,  had  suffered  from  diabetes  for 
about  one  year.  The  attack  of  middle- 
ear  inflammation  was  induced  as  the 
result  of  influenza,  and  was  soon  com- 
plicated by  mastoid  involvement.  When 
opened,  extensive  bone  disease  was  found 
present.  J.  E.  Sheppard  (Med.  News, 
May  2,  '9G). 

Bouchardat  dwells  upon  the  diminu- 
tion of  the  memory  and  the  existence  of 
a  growing  indifference;  the  loss  of  apti- 
tude for  any  intellectual  work,  a  tend- 
ency to  anger,  melancholy,  and  hypo- 
chondria. It  appears  to  me  that  this 
author  has  laid  the  colors  on  rather 
heavily  in  painting  his  picture;  mental 
symptoms  are  not  usually  met  with  in 
diabetic  subjects  independently  of  the 
many  cases  in  which  heredity  plays  an 
important  part. 

Sugar  in  the  urine  is  not  at  all  com- 
mon among  the  insane.  Forty  cases  ob- 
served who  had  diabetic  relations,  10  of 
them  having  diabetic  parents  or  grand- 
parents, 14  having  diabetic  brothers  or 
sisters,  12  having  aunts  or  uncles  and 
.  3  cousins  suffering  from  tliis  disease. 
Besides  these  there  were  12  insane  pa- 
tients who  had  insane  and  diabetic  rela- 
tives and  10  patients  wlio  were  both 
insane  and  diabetic.  Nearly  all  the 
cases  of  insane  diabetics  were  affected 
with  melancholia.  Tlie  patients  who  had 
been  diabetic  and  had  then  become  in- 
sane had  almost  all  lost  some  or  all  of 
the  symptoms  of  tlic  diabetes  during  the 


period  of  their  insanity.  Mallet  (Bull, 
de  la  Soe.  Anat.,  Nov.,  '90). 

Diabetes  is  a  disease  which  often  shows 
itself  in  families  in  which  insanity  pre- 
vails; the  two  diseases  are  certainly 
found  to  run  side  by  side,  or  alternately 
with  one  another,  more  often  than  can 
be  accounted  for  by  accidental  coin- 
cidence or  sequence.  Maudsley  ("Pathol- 
ogy of  Mind,"  p.  113,  79). 

The  psychoses  which  develop  in  the 
course  of  diabetes  usually  take  the  form 
of  melancholia.  It  is  rarely  that  mani- 
acal excitement  is  observed,  circular  in- 
sanity being  oftener  seen.  Finder  (In- 
augural Dissertation,  '92). 

Three  cases  of  diabetes  seen  com- 
plicated with  mental  disturbances.  In 
the  first  case  there  was  melancholic  de- 
pression with  suicidal  ideas;  in  the  sec- 
ond, mental  debility;  and  in  the  third 
considerable  pruritus  vulvae  with .  gen- 
eral uneasiness.  In  all  three  cases  there 
were  no  hereditary  influences.  S.  lerzy- 
kowski  (Nowiny  Lekarske,  July,  Aug., 
'93). 

Investigation  carried  on  at  the  Ban- 
stead  Asylum  and  extending  over  a  period 
of  eighteen  months.  Between  the  11th 
of  January,  1894,  and  the  25th  of  June, 
1895,  there  were  (excluding  transfers) 
208  males  admitted  to  the  asylum;  and 
in  175  of  these  an  examination  of  the 
urine  was  made  within  forty-eight  hours 
after  admission.  In  12  in.stancca,  or  in 
C.85  per  cent,  of  these  175  cases,  sugar 
was  almost  certainly  proved  to  be  pres- 
ent. The  following  table  indicates  the 
varieties  of  mental  disease  under  which 
these  admissions  labored,  and  the  dis- 
tribution among  them  of  the  12  exam- 
ples of  glycosuria: — 

Congenital  Cases....  2 

Epileptic  Insanity...  18 

General    Paralysis. . .  30              3 

Mania   43 

Melancholia  55              6 

Delusional  Insanity. .  5 

Organic  Dementia...  (5              2 

Senile  Insanity 10              1 

Totals   175  12 

C.  Hubert  Bond  (Jour,  of  Mental 
Science,  Jan.,  '90). 


DIABETES  MELLITUS.    SYjMPTOMS. 


435 


However,  when,  as  has  been  remarked 
by  Bernard  and  Fere,  an  improvement 
in  the  mental  condition  occurs  during 
the  antidiabetic  treatment,  one  would  be 
inclined  to  admit  a  certain  relation  be- 
tween mental  symptoms  and  the  diabetic 
dyscrasia.  The  same  conclusion  is 
reached  when  the  glycosuria  and  mani- 
acal symptoms  alternate.  Cases  of  this 
kind  have  been  reported. 

Vascular  System. — The  lesions  of  the 
heart  have  been  indifferently  studied 
until  of  late.  Among  380  diabetics 
Mayer  has  observed  cardiac  complica- 
tions in  82. 

Of  380  cases,  337  were  in  the  first  stage 
of  diabetes  and  47  in  tlie  second  stage; 
of  the  latter  20  were  under  observation 
during  both  stages.  Increased  cardiac 
volume,  either  from  hypertrophy  or  dila- 
tation, is  much  more  frequent  in  dia- 
betes than  one  would  suppose  from  the 
literature,  it  being  found  without  other 
anatomical  lesions  in  82  of  the  380  cases. 
J.  Mayer  (Zeit.  f.  klin.  Med.,  B.  14,  H.  3, 
'88). 

These  patients  are  either  of  very  deli- 
cate constitutions,  with  the  heart  weak 
and  irregular,  or  they  are  obese  diabetics, 
with  the  face  red  or  cyanosed,  who  pre- 
sent a  strong  cardiac  impulse,  and  signs 
of  dilatation  of  the  heart,  either  with 
or  without  atrophy.  These  patients  are 
liable  to  die  suddenly.  Such  cases 
should  not  be  confounded  with  the  true 
diabetic  coma;  moreover,  they  differ 
from  the  latter  by  the  absence  of  ace- 
tonuria  and  by  the  suddenness  of  death. 
Very  often  it  is  after  a  voyage  or  fatigue 
of  some  kind  that  these  patients  fall 
into  a  state  of  collapse,  with  cold  ex- 
tremities; small,  feeble  pulse;  a  loss  of 
consciousness,  more  or  less  rapid;  and 
-death  in  a  few  hours. 

Five  cases  of  diabclic  ansina  pectoris; 
in  one  sudden  dcith  during  attack. 
Vergely  (Jour,  de  Mfd.  de  Bordeaux,  '94). 


There   are   also   mixed   cases,   where, 
with  a  weak  heart,  there  is,  at  the  same 
time,  autointoxication.     I  have  myself 
observed  three  such  cases.    The  anatom- 
ical examination  of  the  heart  shows  the 
myocardium  rather  atrophied  and  pale. 
In  Virchow's  necropsy  the  heart  was 
enlarged  in  nine  cases  out  of  si.\ty-nine, 
and   exclusive   of   those   in  which   there 
was  enlargement  from  anatomical  causes 
(vascular,  valvular,  or  renal  disease),  a 
percentage  of  13.     JIayer  (Zeit.  f.  klin. 
Med.,  B.  14,  H.  3,  '88). 

Of  the  patients  who  died  of  diabetes 
at  the  Berlin  Charite  10  per  cent,  had 
cardiac  enlargements  without  valvular 
or  arterial  lesions  or  renal  disease.  0. 
Israel  (Annual,  '89). 

Arteriosclerosis  is  exceedingly  com- 
mon in  diabetics.  Ferraro  dwells  par- 
ticularly upon  generalized  endarteritis. 
According  to  him,  the  atrophic  and  ne- 
crotic lesions  reported  in  various  organs 
are  due  to  this  endarteritis. 

In  the  last  11  years  there  have  been 
26  cases  of  diabclic  gangrene  admitted 
to  the  wards  of  St.  Thomas's  Hospital. 
From  a  study  of  these  cases  the  follow- 
ing conclusions  may  be  noted:  1.  That 
it  yet  remains  to  be  proved  that  true 
gangrene  (excluding  death  from  acute 
specific  processes,  wliich  may  occur  in 
any  subjects  and  at  any  age)  occurs  in 
diabetic  patients  unaccompanied  by  such 
arterial  disease  as  would  of  itself  produce 
the  gangrene.  2.  That  the  glycosuria 
may  or  may  not  precede  the  gangrene, 
but  is  not  usually  accompanied  by  other 
signs  of  diabetes.  3.  That  septic  wounds 
may  produce  a  glycosuria,  which  van- 
ishes when  the  septic  process  is  removed. 
4.  That  individuals  suffering  from  sep- 
tic processes  are  often  on  the  border-land 
of  glycosuria.  5.  That  gangrene  may 
aggravate  a  preexisting  glycosuria.  0. 
That  the  arterial  disease  is  sometimes 
that  which  accompanies,  or  is  produced 
by,  chronic  renal  disease.  7.  Tliat  it  has 
yet  to  be  proved  that  neuritis  can  pro- 
duce any  gangrene  comparable  to  that  of 
the  so-called  diabetic  gangrene.  8.  That 
the  best  chance   of   recovcrv   is   ofTered 


436 


DIABETES  MELLITUS.    SYINIPTOMS. 


by  removal  of  the  limb  near  the  trunk, 
and  that  this  measure  should  be  under- 
taken before  the  patient  is  reduced  by 
septic  absorption.  9.  That  the  presence 
of  glycosuria  may  be  an  indication,  in- 
stead of  a  contra-indication,  for  opera- 
tion. C.  S.  Wallace  (Lancet,  Dec.  23, 
'99). 

(Edema,  which  is  quite  common  in 
diabetes,  is  not  alwaj's  symptomatic  of 
an  affection  of  the  heart.  It  may  pos- 
sibly be  due  to  a  complication  of 
Blight's  disease  of  the  kidneys,  but  this 
is  extremely  rare;  to  a  venous  throm- 
bosis, of  which  examples  have  been  re- 
ported by  Pavy,  Gull,  Dionis  des  Car- 
rieres,  Leudet,  Potain,  and  others. 
Sometimes  there  appear  to  be  active 
tumefaction  and  other  inflammatory 
phenomena  that  are  apparently  due  to 
vasomotor  disturbances.  In  many  cases 
the  cedema  depends  upon  the  impaired 
nutrition  of  the  vessels  caused  by  the 
dyscrasia. 

Pulmonary  Apparatus.  —  The  most 
frequent  complication  in  this  direction 
is  pulmonary  phthisis.  At  least  one- 
third  of  the  cases  of  diabetes  treated  in 
the  hospitals  are  on  account  of  this. 
The  lesions  of  diabetic  phthisis  are  al- 
most always  those  of  bacillary  tuber- 
culosis. The  exceptions  met  with  are 
cavities  following  pulmonary  gangrene, 
which,  as  has  been  remarked  by  some 
clinicians,  have  not  the  usual  foetidness. 
There  are  also  ulcerations  due  to  a 
fibrous  ulcerative  pneumonia  (Mar- 
chand).  Dreschfcld,  Fink,  and  others 
have  reported  similar  cases.  After  phthi- 
sis, pneumonia  is  a  serious  complication 
of  diabetes. 

Pneumonia  is  rare  in  diabetes.  In 
700  cases  of  diabetes  only  7  cases  of 
[ineumonia  observed,  not  counting  1  case 
of  l)ronf!ho-pn<Miinonia  and  5  of  influenza- 
pneumonia.  In  none  of  these  cases  did 
the  sugar  disappear  during  the  febrile 
period.    The  prognosis  is  always  unfavor- 


able.    Bussenius    (Berliner  klin.  Woch., 
No.  14,  '90). 

Diabetics  are  so  prone  to  bacterial  in- 
vasions because  the  glucose  has  a  favor- 
able effect  on  bacterial  growth,  the  sugar 
lowers  the  resistance  of  the  tissues,  and 
the   diabetic   cachexia   and   the  lessened 
alkalinity  of  the  blood  assist.    As  result 
of  examinations  in  twenty-nine  cases  it 
was  found  that  the  most  frequent  com- 
plication was  tuberculosis  (41  per  cent.). 
Honl  (Wiener  klin.  Eund.,  No.  IG,  '98). 
It    may    begin    like   ordinary    pneu- 
monia.   I  have  seen  several  such  cases. 
The  temperature  does  not  differ  from 
that  usual  in  pneumonia,  and  the  urine 
remains,  notwithstanding  the  fever,  at 
its  usual  ratio.     There  are  also  cases 
of  rapid  pneumonia,  of  which  I  have 
observed  several.     In  the  primary  con- 
gestive period  death  may  ensue  in  a  few 
hours.     Pneumonia  is  principally  met 
with  in  diabetics  presenting  intense  gly- 
cosuria. 

Digestive  Apparatus. — The  gums  are 
usually  red  and  tumefied.  Dental  alve- 
olo-periostitis  exists,  as  a  rule,  when  the 
diabetes  dates  back  several  years.  The 
teeth  soon  become  loose  in  the  alveoli 
and  fall  out,  and  dental  caries  frequently 
exists.  In  arthritic  diabetes  pharyngitis 
is  often  present,  or,  at  all  events,  con- 
gestion of  the  pharynx,  with  the  ex- 
pectoration of  sanguineous  mucus. 

Form  of  pharyngitis  symptomatic  of 
diabetes  or  albuminuria  observed.  There 
is  at  first  a  slight  difficulty  in  degluti- 
tion, a  sensation  of  pressure  in  the 
throat,  and  a  deposit  of  mucus  which 
annoys  the  patient  considerably.  An 
examination  of  the  throat  shows  the 
j)illar  of  the  fauces  and  the  posterior 
portion  of  the  pharynx  to  be  reddened, 
the  mucous  membrane  red,  swelled,  and 
frequently  covered  by  a  layer  of  glairy 
mucus.  Garel  (Universal  Med.  Journal, 
Dec.,  '94). 

Laryngeal  vertigo  may  also  occur,  but 
this  symptom  l)clongs  rather  to  the 
arthritis  than  to  the  diabetes. 


DIABETES  MELLITUS.    SYMPTOMS. 


437 


Diabetic  ulceration  of  the  throat  not«d 
in  five  cases.    Ulcers  have  a  tendency  to 
increase   in   depth   and   extent,   and   are 
extremely    painful.      These     ulcerations 
occurring  in  diabetics  do  not  present  any 
characteristic     appearance     or    location. 
W.     Frcudenthal     (Ijarjngoscope,     Feb., 
1900). 
The  stomach  is  dilated  in  all  cases  of 
polyphagia  diabetes.    In  the  latter  cases 
the  digestion  is  apparently  accomplished 
much  more  readily  than  one  would  sup- 
pose, in  view  of  the  enormous  quantity 
of  food  taken,  but  this  is  often  only  ap- 
parently  the   case,   as,   notwithstanding 
the  absence  of  symptoms  of  indigestion,  i 
the  food  is  badly  digested.    The  hydro- 
chloric acid  is  often  absent  in  the  gastric 
juice    (Rotenstein,    Gans,   Honigmann). 
Sometimes  there  are  lesions  of  the  mu- 
cous tract  (interstitial  gastritis,  atrophy 
of  the  glands);  in  other  cases  no  distinct 
lesions    have   been   found.      Gans   and 
Honigmann   claim  to  have  found   hy- 
peracidity in  certain  cases. 

The  disturbances  of  the  intestinal  di- 
gestion are  less  known,  because  they  are 
less  accessible  for  investigation. 

Among  140  diabetic  patients  Seegen 
found  the  liver  enlarged  in  28:  about  20 
per  cent.  Others  have  found  a  greater 
proportion  of  enlarged  livers. 

In  GO  per  cent,  of  diabetics  there  is  a 
manifest  change  in  the  liver,  usually  in 
the  right  lobe.  The  density  of  the  organ 
is  increased  in  one-third  and  its  sensi- 
tiveness in  one-fourth  of  the  cases.  It 
is  usually  increased  in  size,  this  increase 
consisting  of  elements  of  induration. 
GlCnard  (La  Semaine  MCd.,  Aug.  3,  '00). 
In  diabetics  the  function  of  the  liver 
is  unimpaired;  cirrhosis  and  other  in- 
tercurrent affections  diminish  or  abolish 
glycosuria.  Dujardin-Beaumetz  (Bull. 
G6n.  de  Thfr.,  Nov.  15,  '91). 

In  case  of  diabetes  due  to  influenza 
liver  weighed  seven  pounds;  hyper- 
trophic cirrhosis  with  pigmentation 
throughout  hepatic  cells,  portal  spaces, 
and  biliary  ducts  and  vessels.    Pancreas 


large    and    striated;    glands    dissociated 
by  fibrous  tissue;   cells  infilliated  with 
pigment.     De  ilassary   (Bull,  de  la  Soc. 
Anat.,  July  10,  '95). 
I  have  for  a  long  time  insisted  upon 
the  fact  that  during  life  the  liver,  being 
gorged  with  blood,  presents  a  greater 
volume    and    consistency    than   in    the 
cadaver.    The  differences  concerning  the 
condition  of  the  liver  in  diabetes  are, 
in  a  measure,  due  to  this  fact.    In  cer- 
tain subjects  attacked  with  severe  dia- 
betes, a  brownish  color  of  the  skin,  and 
especially  that  of  the  face,  similar  to 
that  witnessed  in  Addison's  disease. 

Case  of  diaidte  hronzi,  of  which  only 
9  certain  cases,  all  by  French  observers, 
and  2  doubtful  ones  have  been  published. 
Marie  (La  Semaine  MC'd.,  May  22,  '95). 

The  liver  is  then  atrophied  and  hard, 
and  there  may  be  ascites.  Hanot  and 
Chauffard  published  two  cases  of  this 
kind  in  1882.  Cases  were  afterward  re- 
ported by  Letulle,  Hanot  and  Schach- 
mann,  Brault  and  Galhard,  Barth,  and 
others.  Upon  section,  the  liver  is  found 
hard  and  distinctly  and  uniformly 
sclerotic,  and  a  microscopical  examina- 
tion shows  the  hepatic  cells  to  be  in- 
filtrated vith  yellowish-brown  or  black 
granulations,  while  at  certain  points 
there  are  large  black  masses.  The  scle- 
rotic connective  tissue  shows  by  its  topo- 
graphical distribution  the  existence  of 
bivenous  cirrhosis.  In  the  portal  spaces 
obliterative  endarteritis  is  found,  with 
net-works  of  biliary  pseudocanaliculi, 
masses  of  pigments,  and  vestiges  of  de- 
stroyed hepatic  cells. 

The  liver  is  the  seat  of  predilection 
for  deposits  of  pigment,  but  it  has  also 
been  found  in  the  pancreas  (Hanot  and 
Chauffard);  also  in  slight  quantities  in 
the  kidney,  and  even  in  the  heart. 
Finally,  as  I  have  already  mentioned 
above,  it  occurs  in  the  skin  itself. 

The  quantity  of  iron  chemically  de- 


438 


DIABETES  MELLITUS.    SYJIPTOMS. 


termined  in  the  pigmented  organs  is 
variable:  Quincke  found  in  a  case  an 
enormous  quantity  of  dry  matter.  The 
liver  was  said  to  contain,  in  all,  27 
grammes.  Zaleski  justly  remarks  that 
this  pigmentation  is  not  characteristic 
of  iron. 

Urinary  System. — Urinary  complica- 
tions are  very  common.  First  there  are 
those  due  to  previous  morbid  conditions 
(gout,  for  instance),  and,  in  particular, 
there  are  those  which  depend  upon  the 
diabetic  dyscrasia,  and  which,  as  is 
known,  are  complex  in  the  case  of  gravel 
diabetes. 

The  renal  lesion  most  common  in  dia- 
betes has  been  reported  by  Armanni  and 
fully  described  by  Strauss. 

It  affects  exclusively  the  zona  limitans, 
where  it  invades  the  straight  tubules  of 
Henle,  which  may  be  either  large  or 
slender;  sometimes,  likewise,  some  of 
the  collecting  tubes  (Strauss).  As  to  the 
localization,  there  are  individual  varie- 
ties; in  one  instance  it  was  found  ex- 
clusively in  the  ascending  branch  of  the 
loop. 

Armanni  regarded  this  lesion  as  a 
Jiyaline  metamorphosis.  Ehrlich,  with 
the  aid  of  iodized  gum,  proved  that  it  is 
really  an  infiltration  of  the  cells  by  the 
glycogenic  substance.  He  regarded  it 
as  a  constant  symptom  in  diabetes;  but 
this  opinion  appears  to  be  somewhat  ex- 
aggerated. At  all  events,  this  lesion 
proves  the  facility  with  which  the  or- 
ganism synthetically  transforms  the 
sugar  into  glycogen.  Ehrlich  thought 
that  the  sugar  so  transformed  was  that 
contained  in  the  urine.  Strauss — basing 
his  opinion  upon  the  fact  that  the  lesion 
is  localized  in  the  zona  limitans  in  the 
neighborhood  of  the  capillaries  inter- 
posed between  the  uriniferous  tubules — 
is   inolinod    to   bolicvG    that   this   sugar 


comes  from  the  blood  of  these  capilla- 
ries. 

[In  support  of  this  hypothesis  the  fact 
may  be  advanced  that  the  glycogenic 
infiltration  may  take  place  in  other 
organs  besides  the  kidneys;  the  brain, 
for  instance  (Futterer).  Very  recently 
Strauss  observed  that  the  glycogenic 
reaction  is  sometimes  absent,  and  that 
there  is  only  a  hyaline  substance.  R. 
Lepine.] 

A  method  for  detecting  and  fixing 
sugar  in  the  organs  just  at  the  place  of 
its  excretion.  Observations  made  on  the 
kidneys  of  rabbits,  diabetes  having  been 
produced  experimentally.  The  kidney 
is  removed  rapidly,  and  a  small  portion 
is  placed  for  fifteen  to  twenty  minutes 
in  a  watery  solution  of  phenylhydrazin 
and  glacial  acetic  acid,  previously 
warmed  in  a  water-bath.  It  is  then 
washed  in  water  acidified  with  weak 
acetic  acid,  hardened  in  10-per-cent. 
formol  solution,  frozen,  and  sections  cut. 
The  sections  showed  the  characteristic 
yellow  needles,  indicating  the  presence 
of  sugar,  chiefly  in  the  interstitial  spaces 
between  the  uriniferous  tubules.  The 
crystals  were  much  more  scanty  in  the 
capsules  of  the  glomeruli,  while  in  the 
lumina  of  the  uriniferous  tubules  they 
were  almost  absent.  The  chief  masses  of 
crystals  were  certainly  situated  in  the 
interstitial  vascular  and  lymph-spacea. 
Seelig  (Archiv  f.  experiment.  Path.  u. 
Pharm.,  B.  37,  H.  2,  3). 

In  certain  cases  of  severe  diabetes,  par- 
ticularly when  death  has  been  caused  by 
coma,  Ebstein  has  seen  a  peculiar  altera- 
tion in  the  epithelium  of  the  convoluted 
tubules  in  which  circumscribed  areas 
alternate  with  normal  portions.  Accord- 
ing to  Albertoni,  this  lesion  is  due  to  the 
acetone  or  to  the  acids  which  exist  in 
the  blood  in  severe  diabetes. 

Quite  recently,  and  only  in  cases  in 
which  death  occurred  during  coma, 
Fichtncr  has  reported  a  very  circum- 
scribed alteration  in  the  cells  of  the  con- 
voluted tubules,  which  consists  of  an 
infiltration  of  fat  at  the  base  of  these 


DIABETES  MELLITUS.    SYMPTOMS. 


439 


cells,  which  is  detected  by  osmic  acid.  1 
have  also  met  with  this  alteration,  to 
which  the  attention  of  pathologists 
should  be  directed. 

In  cases  of  diabetes  C44  post-mortem 
e.xaminations  pcrfoinietl.  The  condition 
of  the  kidneys  was  carefully  noted  in 
241  of  these  cases.  In  the  remainder 
they  were  reported  healthy,  or  only  the 
gross  appearances  were  noted.  Of  the 
241  eases,  G8  are  reported  as  hyper- 
trophic; 52  as  hyperfemic;  94  as  the 
seat  of  a  nephritis;  17  as  having  fatty 
degeneration;  7  had  epithelial  accumula- 
tion; 2  had  cysts;  and  1  multiple  ab- 
scess. Colcord  (Kansas  Med.  Jour.,  Apr., 
'91). 

Lesions  similar  to  those  in  Bright's 
disease  rarely  occur  in  the  diabetic 
kidney. 

Several  authors  have  dwelt  upon  the 
frequency  of  cystitis  in  diabetic  subjects. 

A  complication  which  is  much  more 
rare  is  pneumaluria,  in  which  the  pa- 
tient toward  the  end  of  micturition 
ejects  a  jet  of  gas  through  the  urethra. 
In  a  patient  observed  by  Mueller,  the 
gas,  which  was  collected  under  water, 
was  composed  as  follows:  li,  from  44  to 
57  per  cent.;  N,  from  33  to  35;  C0„, 
from  9  to  19;  0,  traces;  CH^,  traces. 
Freshly-voided  urine  contained  1  per 
cent,  of  sugar,  but  sometimes  there  was 
no  trace  of  it.  There  is  no  doubt  that 
the  phenomenon  of  the  fermentation  of 
the  sugar  is  due  to  the  presence  of  micro- 
organisms in  the  bladder. 

Skin. — The  cutaneous  complications 
occurring  in  diabetes  are  pruritus,  ec- 
zema, and  gangrenous  lesions.  The 
pruritus  may  exist  without  any  apprecia- 
ble lesions.  It  affects  the  genital  organs, 
especially  the  glans  penis  in  men.  In 
women  it  is  much  more  painful,  affect- 
ing the  vulva.  It  gives  rise  to  an  itch- 
ing, burning  sensation,  with  exacerba- 
tions, which  may  cause  insomnia  and 
various  nervous  symptoms.     Sometimes 


it  occurs  early  and  forms  one  of  the 
symptoms  revealing  the  existence  of  the 
disease.  Diabetic  eczema  is  of  two  varie- 
ties: either  genital,  in  which  case,  like 
the  pruritus,  it  appears  to  be  due  to  the 
local  irritation  caused  by  the  sugar,  or 
general,  when  it  occurs  principally  in 
arthritic  subjects. 

Chronic  eczema,  located  in  the  genital 
organs  in  women,  may  be  pachydermic. 
(Fournier.) 

The  gangrenous  dermatoses  have  been 
carefully  studied  by  Marchal,  of  Calvi, 
and  more  recently  by  Kaposi. 

Furuncle  and  anthrax  frequently  com- 
plicate diabetes.  Anthrax  presents  a 
somewhat  peculiar  type:  beginning  in- 
sidiously, and  with  but  little  pain;  the 
oedema  is  slight  and  the  febrile  reaction 
is  either  slight  or  does  not  exist.  Very 
frequently  the  affection  is  complicated 
with  a  phlegmon  or  with  gangrene. 

Diabetic  gangrene  is  not  nearly  so 
rare  as  most  surgeons  suppose.  Fourteen 
cases  observed.  T.  G.  Morton  (Philadel- 
phia Med.  Times.  Jan.  1,  "89). 

Gangrene  of  diabetes  not  believed  to 
be  due  to  the  presence  of  sugar  in  tha 
affected  tissues,  but  to  the  ill  results 
which  follow  infective  processes  in  the 
diabetic.  Infection  of  the  skin  in  these 
patients  is  a  common  accident.  There 
is  usually  itching  and  scratching,  and  by 
this  means  pyogenic  organisms  obtain 
entrance.  Gussenbaucr  (Wiener  med. 
Blat.,  Feb.  2,  '99). 

The  gangrene  may  be  primary  in  dia- 
betics, without  any  previous  phlegmon 
or  anthrax.  In  this  case  it  is  dry  or 
mummified,  like  senile  gangrene.  It 
begins  most  frequently  in  the  toes,  and 
has  been  seen  to  originate  simply  in  a 
local  asphyxia.  I  have  already  men- 
tioned the  diabetic  perforating  ulcer 
(see  Nervous  Complicatioxs). 

Diabetic  gangrene  is  not  infrequently 
the  first  symptom  to  attract  attention 
to    diabetes    in    an    apparently-healthy 


440 


DIABETES  MELLITUS.    SYMPTOMS. 


person.  Hence  the  necessity  of  examin- 
ing the  urine  in  cases  of  gangrene.  Roser 
(Berliner  klin.  Woch.,  June  22,  '96). 

If  a  gangrenous  inflammation  occur  in 
comparatively-young  persons,  the  urine 
should  be  examined,  as  diabetics  may 
thus  suffer  from  gangrenous  inflamma- 
tions. Diabetic  gangrene  often  arises  in 
the  presence  of  arteriosclerosis;  in  9  out 
of  11  cases  observed  severe  arterioscle- 
rotic changes  were  present  in  the  small 
vessels.  Koenig  (Berliner  klin.  Woch., 
June  22,  '96). 

A  form  of  lichen  resembling  exan- 
thema has  been  described  in  diabetes.  In 
a  patient  seen  by  Eobinson  touching  the 
tumor  caused  a  burning  sensation. 

Nine  cases  observed  where  psoriasis 
co-existed  with  gout  or  diabetes,  or 
both;  a  causal  relation  between  those 
affections  does  undoubtedly  exist.  Karl 
Grube  (Berliner  klin.  Woch.,  vol.  xxxiv, 
No.  52,  p.  1134). 

Cutaneous  disorders  observed  in  dia- 
betes: Generalized  xeroderma,  which  is 
quite  common;  eczematous  dermatic 
manifestations  occurring  in  anj'  region 
of  the  skin,  especially  prone  to  attack 
the  flexor  surfaces,  and  more  especially 
the  genital,  anal,  and  inguinal  regions; 
furuncular  and  carbuneular  manifesta- 
tions are  quite  frequent  in  this  condi- 
tion, and  are  found  generally  in  the 
i  nuchal  and  gluteal  regions;    erythema- 

tous lesions,  some  evanescent,  others  of 
the  graver  kind,  as  erysipelas,  are  com- 
monly present;  gangrene;  dermatitis 
herpetiformis  of  Duhring;  xanthoma 
diabeticorum ;  blastoraycetic  dermatitis. 
S.  Sherwell  (Med.  News,  June  29,  1901). 

Locomotor  Apparatus. — The  cartilages 
may  present  the  lesions  upon  which 
Krawkovv  dwells,  which  are  due  to  a 
deposit  of  glycogen. 

Frerichs  refers  to  the  lightness  of  the 
bones.  They  have  been  found  to  be  ex- 
tremely light  in  some  cases.  I  have 
stated  above  that  in  serious  cases  the 
lime  in  the  urine  is  relatively  increased. 
Perhaps  these  anomalies  liear  less  rela- 
tion to  the  hyperglycacmia  than  to  the 


acid  dyscrasia  of  the  severe  form  of  dia- 
betes, to  which  we  shall  now  refer. 

Diabetic  Coma.  —  Under  this  head 
have  been  grouped  those  cases  in  which 
the  patient  falls,  in  a  very  short  time, 
into  a  comatose  state,  which  is  nearly 
always  mortal. 

Stosch,  in  1828,  appears  to  have  been 
the  first  to  mention  this  dangerous  com- 
plication of  diabetes.  Twenty  years 
later  Front  related  4  cases  of  diabetes 
which  terminated  suddenly  in  death. 
Grisolle,  Bence-Jones,  Fetters,  Balt- 
hazer,  Foster,  Kaulich,  Howship  Dick- 
inson, and  others  have  reported  similar 
cases,  but  the  first  extensive  article  on 
the  subject  is  that  of  Kussmaul. 

Frerichs  separates  these  cases  into  three 
categories.  We  have  already  studied  the 
first  (rapid  death  by  cardiac  paresis,  see 
above).  In  one  of  the  remaining  two  the 
first  appearance  is  not  very  sudden,  there 
being  premonitory  signs:  increased 
weakness,  gastric  disturbances,  anorexia; 
the  breath  and  urine  nearly  always  give 
off  the  penetrating  odor  of  acetone,  and 
the  urine,  after  the  addition  of  perchlo- 
ride  of  iron,  usually  presents  a  red  color. 

Very  frequently,  as  I  have  already  men- 
tioned under  Symptoms,  there  is  a  de- 
cided difference  between  the  quantity  of 
sugar  revealed  by  Fehling's  solution  and 
the  smaller  quantity  registered  by  the 
polarimeter.  According  to  my  observa- 
tions, the  pulse  is  always  accelerated, 
then  cephalalgia  sets  in,  and  a  peculiar 
dyspnoea,  which  is  not  explained  by  aus- 
cultation of  the  lungs,  and  which  is  char- 
acterized by  a  great  frequency  and  depth 
of  the  respiratory  movements.  Occa- 
sionally there  is  cyanosis,  with  lowering 
of  the  temperature,  then  somnolence, 
ending  in  coma  and  death.  The  total 
duration  of  the  symptoms  in  this  variety 
is  from  three  to  five  days. 

In  the  third  category  of  such  cases  the 


DIABETES  MELLITUS.    SYMPTOMS. 


4-il 


dyspnoea  does  not  exist:  the  patient  be- 
comes more  or  less  suddenly  excited  as 
though  intoxicated,  vertigo,  delirium, 
somnolence,  and  coma.  In  this  variety, 
which  is  rather  more  rare  than  the  pre- 
ceding, the  urine  presents  the  same  char- 
acteristics. 

It  is  generally  admitted  that  the 
pathogenic  element  of  diabetic  coma  is 
an  intoxication,  but  it  has  not  yet  been 
established  with  certainty  to  what  sub- 
stance this  is  due. 

Petters — to  whom,  in  1857,  the  dis- 
covery of  acetone  in  the  urine  of  one  of 
his  patients  is  due — does  not  hesitate  to 
attribute  these  accidents  to  the  presence 
of  this  substance.  This  opinion  was  all 
the  more  readily  accepted  during  a  cer- 
tain time,  through  the  fact  that  the 
urine  in  the  majority  of  severe  cases  of 
diabetes  contains  a  considerable  quan- 
tity of  acetone  (up  to  3  grammes  per  day 
— Engel).  Experiments,  however,  have 
not  coincided  with  this  interpretation, 
for  animals  support  much  larger  doses 
without  presenting  the  symptom  of  dia- 
betic coma. 

Gerhardt,  who  in  1865  discovered  the 
fact  that  the  addition  of  perchloride  of 
iron  to  the  urine  of  certain  diabetes  pro- 
duced a  red  color,  thought  that  it  was 
due  to  the  diacetic  ether  which  decom- 
poses readily  in  acetone,  COj,  and  alco- 
hol. Von  Jaksch  attributes  this  colora- 
tion to  the  diacetic  acid;  but  the  fact 
that  the  injection  of  considerable  doses 
of  this  substance  does  not  give  rise  to 
symptoms  resembling  those  of  diabetic 
coma  leads  one  to  doubt  that  the  acci- 
dents of  diabetic  coma  are  solely  due  to 
its  presence. 

Boussingault  formerly  found  as  much 
as  1.6  grammes  of  ammonia  per  litre  of 
diabetic  urine;  this  enormous  daily  ex- 
cretion of  ammonia  appeared  incredible, 
and  Koppe  argued  against  the  exactitude 


of  Boussingault's  method;  but  in  1880, 
Hallerworder  fully  confirmed  the  results 
of  Boussingault,  basing  his  observations 
upon  the  researches  of  Walter,  made  ac- 
cording to  the  directions  of  Schmiede- 
berg. 

[These  researches  proved  the  fact  that 
where  a  mineral  acid  penetrates  into  the 
blood  ammonia  is  formed  in  the  econ- 
omy, by  neutralization.  K.  Lepine.] 
Hallerworder  did  not  hesitate  to  alhrm 
that  in  diabetic  subjects  there  exists  an 
excess  of  acid,  perhaps  lactic  acid.  Sta- 
delmann,  by  treating  all  the  acids  and 
all  the  bases  in  the  urine  as  had  been 
done  by  Goethgens,  found  that,  while  in 
the  normal  urine  the  known  acids  exceed 
the  bases,  the  contrary  is  the  case  in  dia- 
betic urine,  and  that  consequently  there 
must  exist  in  the  latter  some  unknown 
acid.  As  a  matter  of  fact,  from  several 
litres  of  diabetic  urine  Stadelmann  suc- 
ceeded in  directly  extracting  crotonic 
acid,  and  Minkowski,  continuing  his  re- 
searches, proved  that  the  crotonic  acid 
does  not  pre-exist  in  the  urine,  but  that 
it  is  a  product  of  the  decomposition  of 
oxybutyric  acid.  At  the  same  time 
Kiilz,  in  view  of  the  fact  that  the  urine 
of  some  diabetics  deviates  strongly  to 
the  left  after  the  fermentation  of  the 
sugar,  discovered,  on  his  side,  that  this 
deviation  is  due  to  a  substance  of  a  com- 
position identical  with  that  of  the  known 
oxybutjTic  acids,  but  differing  from  the 
latter  through  the  property  of  deviating 
to  the  left.  Deichmiiller,  ZjTnanski  and 
Tollens,  Lupine  and  Hugounenq,  and 
others  have  confirmed  the  existence  of 
oxybutyric  acid  in  the  urine  of  certain 
diabetics. 

In  twenty-one  cases  of  diabetic  coma 
all  patients  eliminated  large  quantities 
of  acid;  but  n  comatose  condition  ma,j 
be  due  to  increased  destruction  of  nitrog- 
enous material  in  other  maladies,  and 
administration  of  alkalies  is  without 
effect;   hence,  coma  is  not  due  to  acid 


442 


DIABETES  MELLITUS.     SYMPTOMS. 


intoxication.  As  means  of  restricting 
nitrogenous  destruction,  S  ounces  of  fat 
daily;  milk  or  levulose  if  disgust  occur. 
KJemperer  (Miinch.  med.  Woch.,  May 
14,  '95). 

The  most  probable  cause  of  diabetic 
coma  is  the  formation  and  retention  in 
the  organism  of  the  decomposition-prod- 
ucts of  sugar,  such  as  acetone,  diacetic 
acid,  and  more  especially  of  beta-oxy- 
butyric  acid.  These  acids  have  fre- 
quently been  found  both  in  the  blood 
and  in  the  urine  of  patients  suffering 
from  diabetic  coma.  Among  the  pre- 
disposing causes  of  coma,  age  ranks  as  an 
important  one,  this  complication  of  dia- 
betes being  especially  frequent  between 
20  and  40  years  of  age.  Among  other 
causes,  Cassoute  notes  an  exclusively- 
meat  diet  and  many  agents,  such  as 
opium,  which  tend  to  restrain  and  di- 
minish the  glycosuria.  Cassoute  (Gaz. 
des  Hfip.,  '90). 

According  to  our  present  knowledge, 
it  may  be  definitely  stated  that  diabetic 
coma  is  due  to  an  acid  intoxication  pro- 
duced by  the  circulation  of  excessive 
quantities  of  beta-oxybutyric,  and  pos- 
sibly also  diacetic,  acid  in  the  blood, 
these  being  the  products  of  the  decom- 
position of  the  body-albumins.  Thomas 
B.  Futcher  (N.  Y.  Med.  Jour.,  vol.  Ixvi, 
No.  25,  p.  821,  '97). 

It  is  generally  admitted  that  acetone 
arises  from  the  decomposition  of  oxy- 
butyric  acid,  according  to  the  following 
equations: — 

C.U.O.  +  0  =  C.H,03  +  H,0 
oxybutyric  acid      diacetic  acid 

C.H.O.  =  CsH.O  +  CO. 
acetone 

Von  Jaksch  has  supposed  that  the  ace- 
tone, instead  of  originating  from  the 
diacetic  acid,  might,  on  the  contrary, 
give  rise  to  it,  by  combining  with  the 
formic  acid. 

CH>0,  +  C.H.O  -f  O  =  C.H.O,  +  11,0 
formic  acid 

The  quantity  of  o.vybutyric  acid  elimi- 
nated per  day  is  not  insignificant,  for  4 
grammes  of  ammonia  neutralize  about 


30  grammes  of  oxybutyric  acid,  and  some 
diabetics  excrete  more  than  4  grammes 
of  ammonia  daily. 

There  can  hardly  be  a  certain  parallel- 
ism between  the  excretion  of  ammonia 
and  that  of  the  oxybutjTic  acid. 

The  ammonia  may  either  be  saturated 
with  other  less  known  acids  or  its  forma- 
tion may  be  due  to  other  factors. 

It  must,  moreover,  not  be  forgotten 
that  oxybutyric  acid  is  not  peculiar  to 
diabetic  coma.  Minkowski  has  elimi- 
nated 3  grammes  from  a  non-diabetic 
woman,  attacked  by  pseudoscorbutus  in 
a  case  of  lateral  amyotrophic  sclerosis. 

To  sum  up,  there  seems  to  be  no  doubt 
that  in  a  certain  number  of  cases  of 
severe  diabetes  the  blood  is  less  alkaline. 
Is  this  lesion  the  cause  or  the  effect  of 
the  symptoms?  I  am  inclined  to  believe, 
with  the  majority  of  authors,  that  it  is 
in  part  the  cause,  and  I  am  surprised 
at  the  opposite  interpretation  given  by 
Klemperer,  who  says  that  the  blood  is 
acid  because  there  is  coma.  Clinical  ob- 
servations seem  to  me  to  contradict  this 
view,  for  the  lack  of  alkalinity  of  the 
blood  precedes  the  beginning  of  the 
coma.  Finally,  the  cases  in  which 
purely-alkaline  treatment,  according  to 
Stadelmann's  method,  has  been  mani- 
festly useful  would  seem  to  favor  the 
opinion  which  I  defend.  I  have  myself 
seen  several  such  cases. 

It  is  likewise  an  incontestable  fact  that 
the  acid  intoxication  is  merely  an  ele- 
ment of  the  diabetic  coma.  It  is  certain 
that  the  kidney  is  not  healthy  when  the 
symptoms  present  themselves  (see  above 
the  lesions  of  Ebstein  and  of  I'ichtner). 
Finally  I  may  mention  lipajmia,  to  which 
English  physicians  attach  a  pathogenic 
value. 

From  a  review  of  opinions  of  various 
well-known  surgeons,  and  from  personal 
limited  ol)servutians,  it  appears  that  the 
presence    of    glycosuria    in    those    indi- 


DIABETES  MELLITUS.    SYJIPTOMS. 


443 


viduals  who  may  have  surgical  diseases 
does  not  in  itself  constitute  an  absolute 
contra-indication  to  any  and  all  surgical 
relief.  Very  great  judgment  must  be 
exercised  in  the  selection  of  cases,  in  the 
determination  of  the  kind  and  extent  of 
the  operation  to  be  performed,  and  the 
strictest  surgical  asepsis  must  be  rigidly 
observed  throughout.  Infection,  when  it 
occurs,  is  from  without,  and  is  the  result 
of  an  error  in  the  technique.  When  in- 
fection does  not  occur,  the  operative 
wounds  heal  kindly,  but  slowly,  espe- 
cially in  granulating  wounds.  The  vas- 
cularity of  the  tissue  must  be  interfered 
with  as  little  as  possible.  Tliis  is  par- 
ticularly so  in  gangrene  of  tlie  extremi- 
ties, in  which  the  statistics  of  Heiden- 
heim,  Kuster,  and  Smith  and  Durham 
sliow  most  conclusively  the  necessity  of 
high  amputations  in  these  conditions. 
Personal  opinion  is  that  it  is  better  to 
cut  down  upon  and  ligate  the  artery  in 
gangrene  of  the  extremities  rather  than 
to  attempt  the  bloodless  amputation  by 
means  of  the  Esmarch  band.  A.  L.  Fisk 
(Annals  of  Surg.,  Apr.,  1900). 

Acute  Form. — Diabetes,  in  the  great 
majority  of  cases,  is  an  affection  pro- 
gressing in  a  chronic  condition,  but  in 
some  cases  the  onset  is  sudden  and  the 
progress  of  the  disease  acute. 

Out  of  77  cases  of  children  traced  to 
their  termination,  14  recovered,  7  im- 
proved, 4  remained  unimproved,  and  52 
died.  C.  Stem  (Archiv  f.  Kinderh.,  B. 
11,  H.  2,  '89). 

Gravity  of  prognosis  of  diabetes  in 
children.  Of  108  cases,  G4  per  cent, 
terminated  fatally.  Prognosis  graver  in 
proportion  as  children  are  younger. 
Wegeli  (Archiv  f.  Kinderh.,  B.  19,  H.  1, 
2,  '95). 

In  adults  proportion  of  grave  cases 
does  not  exceed  5  per  1000.  Worms 
(Bull,  de  I'Acad.  de  M6d.  de  Paris,  July 
23,  '95). 

The  rate  of  mortality  from  diabetes 
has  risen,  in  Paris,  within  the  last  ten 
year.=i,  from  an  average  of  8  in  each 
100,000  population  to  an  average  of  13; 
while  in  Copenhagen  it  has  risen  from 
5  to  8;  and  in  England  and  Wales  it 
has  increased,  in  fourteen  years,  70  per 


cent.,   alter  allowing   for   the   increased 
population.    Saundby  (Editorial,  Modem 
lied,  and  Bact.  Rev.,  Apr.,  '97). 
Authentic  cases  of  this  nature  are  rare, 
because  the  evolution  of  the  disease  may 
actually  have  been  an  incipient  one,  and 
have  remained  unnoticed  up  to  a  certain 
period,  when  there  is  a  sudden  aggrava- 
tion. 

[Loeb  reports   the   case  of  a  chemist 
who,  while  in  good  health,  examined  hia 
own  urine  and  found  it  normal.     Soon 
after  he  became  ill,  and  experienced  vio- 
lent thirst.    At  this  time  the  urine  con- 
tained 8  per  cent,  of  sugar.    Death  took 
place  in  five  weeks.     R.  Lepine.] 
Death  is  not  invariably  the  termina- 
tion of  acute  diabetes.    Several  cases  of 
recovery  have  been  reported.    Holsti  saw, 
in  a  man  41  years  old,  diabetes  having  a 
very  sudden  beginning,  to  judge  by  the 
thirst,  and  which  was  only  subjected  to 
the  dietetic  treatment  six  weeks  later. 
After  three  days  abstinence  from  amy- 
laceous food  the  urine,  which  had  con- 
tained 8.8  per  cent,  of  sugar,  ceased  to 
contain  any,  and  the  future  use  of  amy- 
laceous food  did  not  cause  a  return  of 
the  diabetes.     This  is  assuredly  a  rare 
case.    More  frequently  a  diabetes  having 
an  acute  beginning  passes  to  a  chronic 
condition. 

A  mild  form  of  diabetes  has  sometimes 
been  described  as  intermiitent ;  it  is  due 
in  a  measure  to  the  influence  exerted  by 
a  too  liberal  alimentation.  As  soon  as  a 
proper  diet  is  followed  the  glycosuria 
does  not  exist. 

This  is  not,  properly  speaking,  an  in- 
termittent diabetes.  Such  cases  belong 
rather  to  the  type  of  alimentary  glyco- 
suria. 

Study  of  six  cases  of  recurrent  transi- 
tory diabetes.  The  proportion  of  sugar 
was  very  variable,  but  usually  30  to  40 
g.  a  day.  The  glycosuria  diminished 
rapidly  under  a  rigid  diet.  The  amount 
of  sugar  was  invariably  less  in  the  sec- 
ond and  third  attacks  than  in  the  first, 


444 


DIABETES  MELLITUS.    DIAGNOSIS. 


but  the  attacks  lasted  longer  with  each 
relapse,  1  or  2  g.  of  sugar  persisting  for 
weeks  or  months.  As  a  rule,  there  was 
albuminuria,  which  subsided  with  the 
glycosuria.  The  proportion  of  uric  acid 
was  high.  In  all  cases  there  was  a  mod- 
erate degree  of  polyiiria.  Thirst  and 
hunger  were  never  marked,  but  emacia- 
tion, sense  of  physical  exhaustion,  and 
depression  were  prominent  symptoms; 
these  recurred  with  diminished  intensity 
with  each  attack.  Months  or  years  of 
perfect  health  sometimes  intervened  with 
the  attacks.  In  one  case  ordinary  dia- 
betes supervened.  The  recurrent  transi- 
tory variety  of  diabetes  is  connected  in 
certain  cases  with  a  constitutional  ar- 
thritism,  in  others  with  an  acquired  ar- 
thritic tendency.  Transitory  diabetes  is 
not  dangerous  in  itself;  it  is  the  ex- 
pression of  an  enfeebled  constitution  or 
a  passing  dyscrasia.  Dreyfus  Brissac 
(Sem.  Med.,  Feb.  12,  '97). 

IVue  intermittent  diabetes  is  almost 
independent  of  the  alimentation.  It  has 
been  reported  by  Bence-Jones,  Baudre- 
mont,  and  others.  Saundby  reports  one 
case.  I  have  myself  seen  one  alternate 
with  albuminuria.  This  form  of  dia- 
betes is  principally  met  with  in  arthritic 
and  hysterical  subjects.  Its  appearance 
depends  principally  upon  nervous  causes, 
moral  or  otherwise. 

Diairnosis.  —  A  well-defined  diabetes 
cannot  be  mistaken  by  an  experienced 
physician.  The  general  symptoms  and 
the  glycosuria  establish   the  diagnosis. 

Diagnosis  by  Examination  of  the 
Urine. — If  the  percentage  of  sugar 
found  in  the  urine  is  considerable,  doubt 
is  impossible.  If,  on  the  contrary,  a 
minimum  quantity  is  found,  it  may  be 
questioned  whether  there  is  not  merely 
a  condition  of  temporary  glycosuria. 
This  should  never  be  lightly  decided;  it 
requires  a  careful  watching  during  sev- 
eral days  to  make  sure  of  the  actual  con- 
dition. 

All  caHCB  with  Bugar  in  the  urine  are 
cases  of  true  dialx-tcs,  whether  the  sugar 


be  extremely  small  in  amount  or  even 
be  entirely  absent  for  a  time.  Ebstein 
(Centralb.  f.  innere  Med.,  Nov.  21,  '96). 
The  urine  of  persons  taking  rhubarb, 
santonin,  or  some  other  substances  gives 
a  reaction  that  might  be  mistaken  for 
that  of  sugar.  S.  A.  Hazen  (New  York 
Med.  Jour.,  Jan.  29,  '98). 

It  is  in  the  cases  in  which  lesions  of 
the  nervous  system,  and  particularly  of 
the  brain,  exist  that  the  diagnosis  be- 
comes most  difficult,  and  the  common 
tendency  to  regard  glycosuria  as  a  con- 
secutive symptom  must  be  guarded 
against.  The  diagnosis  is  usually  easier 
where  paraplegia  and  glycosuria  co-exist. 
It  is  a  known  fact  that  a  neuritis  of  the 
lower  members  in  a  diabetic  patient  may 
simulate  iahes  dorsalis,  but  it  would, 
however,  be  a  rare  condition  when  co- 
existing with  glycosuria.  The  following 
are  the  differential  characteristics: — 

1.  The  walk  of  the  patient.  Were 
symptoms  of  diabetes  present  before  the 
motor  disturbances? 

2.  The  symptoms  proper  of  diabetes: 
the  abundance  of  the  urine  and  of  the 
glycosuria,  the  presence  of  acetonuria, 
etc. 

3.  The  symptoms  peculiar  to  tabes, 
particularly  motor  inco-ordination, 
which  is  not  present  in  diabetes;  in  the 
latter  affection  "steppage"  exists,  which 
symptom  does  not  occur  in  tabes. 

Among     symptoms     characteristic     of 
both    tabes   and    diabetes   are   irregular 
areas  of  anaesthesia  or  analgesia;    pares- 
thesitB,    especially    about   the   legs    and 
sexual   organs;    increased   sensitivenesB 
toward  cold;    lancinating  pains;    dimin- 
ished   sexual    vigor;     and    trophic    and 
secretory   disturbances,   such    as   malum 
perforans  pedis,  decubitus,  liypcridrosia, 
and    muscular    atrophy.      Both    diseases 
rorely  occur  together.    W.  Croner  (Zeits, 
f.  klin.  Med.,  vol.  xli,  Nos.  1-4,  1900). 
Besides  these  fundamental  differences, 
there  are  several  other  signs  of  second- 
ary importance,  such  as  shooting  pains, 


DIABETES  MELLITUS.    DIAGNOSIS. 


445 


which,  although  they  may  exist  in  dia- 
betes, as  reported  by  Charcot,  llaymond 
and  Oulmont,  Bernard  and  Fere,  and 
others,  are  of  sufficiently-rare  occur- 
rence. The  vesical  disturbances  existing 
in  diabetes  have  nothing  in  common 
with  the  vesical  and  urethral  attacks 
which  occur  in  tabes;  the  ocular  paraly- 
sis, which  is  a  frequent  symptom  in 
tabes,  very  rarely  occurs  in  diabetes;  in 
those  cases  in  which  there  are  disturb- 
ances of  vision,  an  examination  of  the 
fundus  will  dispel  all  uncertainty:  in 
diabetes  retinitis  will  be  found;  in  tabes 
atrophy  of  the  optic  nerve.  If  the  latter 
lesion  is  not  sufficiently  pronounced  to 
be  recognizable,  it  should  be  remembered 
that  in  the  amblyopia  of  diabetes  the 
optic  disturbance  is  bilateral  from  the 
beginning,  while  in  tabes  it  most  fre- 
quently begins  in  one  eye. 

The  above  refers  to  the  diagnosis  be- 
tween diabetes  and  glycosuria  of  nerv- 
ous origin;  but  the  latter  variety  is  not 
the  only  one  which  may  be  mistaken 
for  diabetes.  I  will  first  refer  to  ali- 
mentary glycosuria,  which  occurs  in  cer- 
tain subjects  after  a  very  copious  in- 
gestion of  the  hydrocarbons;  it  also 
occurs  in  nearly  every  subject  after  the 
ingestion  of  a  sufficient  quantity  of  glu- 
cose during  a  short  space  of  time  {at 
least  200  to  300  grammes  for  certain 
persons).  Alimentary  glycosuria  was 
first  observed  in  certain  cirrhotic  sub- 
jects by  Cotrat,  afterward  by  myself  and 
a  number  of  others  (Quincke  and  oth- 
ers), but  the  affection  is  not  best  seen 
in  cirrhotic  patients.  Krauss  and  Lud- 
wig  observed  a  young  girl  suffering  from 
Basedow's  disease  who,  after  the  inges- 
tion of  from  100  to  200  grammes  of 
pure  glucose,  excreted  very  nearly  17 
per  cent,  of  the  glucose  ingested. 

It  often  happens  that  very  fat  people 
will  show  glucoss  in  their  urine  after  a 


meal  containing  a  fairly  large  quantity 
of  sugar.  The  glucose  disappears  from 
the  urine  of  those  fleshy,  diabetic  pa- 
tients who  are  being  treated  for  obesity 
though  not  placed  upon  a  strict  diabetic 
diet.  The  glycosuria  which  so  often  fol- 
lows traumatic  neurosis  is  due  to  an  ex- 
cessive diet  combined  with  a  lack  of 
active  e.xercise.  Hirschfield  (Med.  News, 
Jan.  28,  '98). 

Eecognition  of  the  "alimentary"  form 
of  diabetes  is  effected  not  only  by   the 
elimination  of  sugar  being  susceptible  of 
control  by  the  exclusion  of  carbohydrate 
matter  from  the  food,  but  also  by  the 
absence    of    the    products,    diabetic    and 
oxybutyric     acids,     of     tissue     breaking 
down.      If    the    ferric-chloride    test    for 
these  products  gives  no  reaction,  case  is 
thus  far  only   in   the  alimentary   form. 
F.  W.  Pavy   (Lancet,  June  23,  1900). 
Chvostek,    at    Meynert's    clinic,    was 
also  able  to  produce  alimentary  glyco- 
suria with  great  facility  in  patients  suf- 
fering  from    Basedow's    disease.      Evi- 
dently  these   patients,   owing  to   their 
nervousness,  are  particularly  predisposed 
to  glycosuria.     In  some  subjects,  on  the 
other  hand,  it  is  almost  impossible  to 
induce  alimentary  glycosuria. 

The  glycosuria  which  sometimes  fol- 
lows certain  acute  maladies,  and  some 
surgical  affections  and  cases  of  poison- 
ing, cannot  well  be  mistaken  for  dia- 
betes, as  the  other  existing  conditions 
would  arouse  the  attention  of  the  phy- 
sician. Moreover,  this  form  of  glyco- 
suria is  alwaj's  very  mild. 

Case  of  myxtrdema  in  which  the  in- 
gestion of  thyroid  tablets  caused  gly- 
cosuria. Ewald  (Deut.  med.  Zeit.,  No. 
GO,  '94). 

Under  fresh  thyroid-gland  diet  animals 
are  affected  with  tachycardia,  consider- 
able emaciation,  polyphagia,  polydipsia, 
and  temporary  glycosuria.  Gcorgiewski 
(Centrnlb.  f.  die  med.  Wissenschaften, 
No.  27,  '95). 

Marked  polyuria  with  glycosuria  is 
produced  in  animals  by  caffeine-sul- 
phonic  acid.  Jacoby  (Archiv  f.  exper. 
Path,  und  Pharm.,  B.  35,  H.  2,  3,  '95). 


446 


DIABETES  MELLITUS.    DIAGNOSIS. 


CUoralamid,  1  'A  to  3  drachms  per 
day,  frequently  causes  glycosuria.  Man- 
chot  (Virchow's  Archiv  fiir  Path.  Anat. 
und  Phys.  und  f.  klin.  Med.,  B.  136,  p. 
368,  '95). 

This  is  not  always  the  case  when  the 
glycosuria  is  due  to  the  ingestion  of 
phloridzin. 

Phloridzin  diabetes  appears  more  in- 
tense when  the  liver  contains  no  gly- 
cogen. Pick  (Archiv  f.  exper.  Path,  und 
Pharm.,  B.  33,  p.  305,  '95). 

It  is  known  that  the  proportion  of 
glucose  contained  in  the  urine  may  be  as 
great  as  in  very  severe  diabetes;  con- 
sequently, there  are  only  two  ways  to 
avoid  being  deceived  by  a  patient  who 
hides  the  fact  of  having  taken  the  phlo- 
ridzin. The  patient  must  be  closely  con- 
fined and  be  deprived  of  phloridzin.  On 
the  other  hand,  the  blood-corpuscles 
must  be  carefully  examined  for  the  re- 
action of  Bremer  (see  farther  on).  In 
cases  of  phloridzic  glycosuria,  this  re- 
action will  not  be  present,  or,  in  the 
worst  case,  will  be  exceedingly  doubtful. 
Since  the  works  of  Blot  it  is  known 
that  sugar  is  frequently  present  in 
women  during  parturition. 

Forty-si.\  women  examined,  9  of  whom 
were  pregnant,  25  delivered,  and  12 
nursing.  In  pregnancy  in  the  last  month 
no  trace  of  sugar  was  observed;  in  10 
women  recently  delivered  the  presence 
of  sugar  was  positively  ascertained;  in 
3  cases  but  slight  traces  were  found,  and 
in  12  others  there  was  no  sugar  present. 
The  glycosuria  appeared  about  from 
three  to  five  days  after  delivery,  during 
the  increased  secretion  of  milk,  disap- 
pearing when  the  secretion  diminished. 
No  glycosuria  was  ob.served  in  nursing 
women.  The  condition  appears  only 
when  the  secretion  of  milk  is  in  excess 
of  that  required  for  the  child.  Berberoff 
(Wratseh,  No.  10,  '03). 

Diabetes  is  a  rare  complication  of 
pregnancy.  Study  of  one  personal  case, 
and  twenty-four  reported  by  other  ob- 
servers.    About    one-half    of    these    ac- 


quired  diabetes    during   pregnancy,   the 
other   half   already   having   the   disease 
before     pregnancy     occurred.       In     the 
former    class    recovery    took    place    in 
about  three-fourths,  with,   however,   an 
exhibition   of  a   tendency  to  recurrence 
in  subsequent  pregnancies.    In  the  class 
in  which  pregnancy  occurred  in  women 
already     subjects     of     diabetes,     safety 
through  delivery  and  the  lying-in  period 
was    apparent    in    about    two-thirds    of 
the  cases.    Death  of  the  foetus  is  noticed 
in  about  one-half  of  the  cases.     Pi'ema- 
ture  delivery  is  observed  in  a  large  pro- 
portion of  the  reported  cases,  due  to  the 
presence  of  the  dead  foetus  rather  than 
the  direct  influence  of  diabetes.     Tliere 
were  0  deaths  in  coma  or  collapse  during 
or  near  the  time  of  labor:  1  in  a  woman 
who  had  diabetes  before  gestation,  while 
5  were  in  patients  who  acquired  the  dis- 
ease during  pregnancy.    Partridge  (Med. 
Record,  July  27,  '95). 
It  may  be  necessary  in  some  cases  to 
question  the  existence  of  a  true  diabetes. 
To  establish  the  diagnosis,  reliance  may 
be  placed  upon  the  fact  that,  in  the  case 
of  a  false  diabetes,  the  secretion  of  milk 
is  always  arrested,  and  that  the  sugar 
contained  in  the  urine  is  not  glucose, 
but  lactose,  which  fact  has  been  estab- 
lished  by   Hofmeister,   and,   after  him, 
Kaltenbach.    It  would  appear,  however, 
according  to  Blot,  de  Sin6ty,  and  sev- 
eral   more    recent   observers,    that    the 
lactose    may    be    partially    transformed 
into  glucose;   so  that  the  presence  of  a 
fermentable  sugar  (glucose)  in  the  urine 
of  a  parturient  woman  would  not  in- 
contestably  prove  the  fact  that  tlie  pa- 
tient was  a  diabetic.     I  may  liere  call 
attention  to  the  fact  that  Mathew  Dun- 
can found  true  diabetes  in  a  pregnant 
woman.    The  child  was  also  said  to  be  a 
diabeticl 

A  gross  error  committed  by  inexperi- 
enced persons  consists  in  regarding  a 
subject  diabetic  whose  urine  reduces  cu- 
pro-polnssic  fluid,  but  which,  in  reality, 
does  not  contain  a  trace  of  sugar.    This 


DIABETES  MELUTUS.    DIAGNOSIS. 


447 


error  is  the  more  regrettable  through  the 
fact  that  the  restriction  to  an  animal 
diet  may  aggravate  the  condition  of  the 
patient  instead  of  improving  it,  for  the 
animal  diet  favors  the  production  of 
reducing  substances  in  the  economy. 
Among  these  substances  are  uric  acid, 
creatinin,  allantoin,  mucin,  oxyphenol, 
pigments,  and  above  all  the  components 
of  glycuronic  acid. 

How  is  this  error  to  be  avoided? 

1.  In  non-albuminous  urine  deprived 
of  the  greater  part  of  its  uric  acid  by  a 
preliminary  cooling  (on  ice)  and  by 
filtration,  the  existence  of  sugar  may  be 
admitted  if  the  reduction  of  the  cupro- 
potassic  fluid  takes  place  in  the  cold 
state,  as  the  reducing  substances  only 
exert  their  action  at  the  boiling-point. 
Sugar,  itself,  in  the  cold  state,  only 
causes  a  reduction  at  the  end  of  several 
hours. 

If  one  does  not  wish  to  wait,  recourse 
may  be  had  to  the  following  process, 
which  is  a  modification  of  that  proposed 
by  Worm-Mueller,  to  determine  whether 
the  reduction  by  heat  is  partially  due  to 
a  small  quantity  of  sugar.  The  exact 
quantity  of  urine  required  to  discolor  1 
cubic  centimetre  of  Fehling's  solution 
must  first  be  determined,  then  a  portion 
of  the  same  urine  is  fermented;  this 
being  accomplished,  it  must  then  be  as- 
certained whether  a  greater  number  of 
cubic  centimetres  will  be  required  to 
discolor  the  same  quantity  of  Fehling's 
solution. 

It  is  clear  that,  if  a  larger  quantity 
is  required,  a  portion  of  the  reducing 
power  was  due  to  a  certain  quantity  of 
sugar.  This  method  is  exact,  and  its 
only  defect  is  that  it  is  not  within  the 
reach  of  the  ordinary  practitioner,  owing 
to  the  precision  of  the  dosages  required. 

To  lessen  the  error  due  to  the  reduc- 
ing substances,  it  has  been  advised  to 


dilute  the  urine  to  the  fifth  and  even  the 
tenth  degree.  Indeed,  this  should  al- 
ways be  done  when  the  urine  is  very 
highly  charged  with  sugar;  but  when 
there  exist  only  doubtful  traces  of  it, 
the  dilution  of  the  urine  is  a  positive 
means  of  not  being  able  to  obtain  the 
sugar.  This  process  should  consequently 
be  rejected. 

On  the  other  hand,  the  following 
method,  which  is,  moreover,  a  classical 
one,  is  perfectly  reliable.  About  4 
grammes  of  Fehling's  solution  are 
poured  into  a  tube;  it  is  heated  to  the 
boiling-point,  then  one  to  two  centilitres 
of  urine,  non-albuminous,  which  is  sup- 
posed to  contain  sugar,  should  be  made 
to  flow  along  the  side  of  the  tube,  which 
should  be  inclined.  It  is  well  to  first 
heat  the  urine  slightly;  otherwise  the 
inclined  tube  should  be  held  above  a 
flame  for  several  moments  in  order  to 
sufficiently  raise  the  temperature  at  the 
point  of  contact  of  the  two  liquids. 
After  a  few  moments,  if  sugar  is  pres- 
ent, a  green  ring  will  be  seen  to  form, 
which  will  then  rapidly  change  to  yel- 
low, and  afterward  to  red,  which  will 
contrast  decidedly  with  the  blue  color 
of  the  subjacent  liquid.  This  reaction 
is  easily  accomplished,  and,  if  a  red  ring 
is  obtained,  it  is  of  great  value,  for  the 
reducing  substances  only  produce  hy- 
drate of  oxydule,  which  is  of  a  yellow 
color. 

Jastrowitz  recently  advised  examina- 
tion, by  means  of  the  microscope,  of  the 
precipitate  of  oxide  of  copper.  As  a 
matter  of  fact,  none  of  the  reducing  sub- 
stances, uric  acid,  creatinin,  nor  the 
components  of  glycosuric  acid,  etc.,  pro- 
duce a  crystalline  precipitate.  Accord- 
ing to  the  author,  these  crystals  are 
tctrahcdral  and  octahedral.  These  are 
actually  the  forms  obtained  when  a 
watery  solution  of  glucose  is  made  to 


448 


DIABETES  MELLITUS.    DIAGNOSIS. 


react  upon  Fehling^'s  solution,  but,  ac- 
cording to  Jastrowitz,  small  spheres  maj' 
also  be  produced  with  urine  containing 
a  slight  amount  of  sugar.  Thus,  when, 
under  the  microscope,  these  (spheres) 
predominate,  provided  they  are  accom- 
panied by  tetrahedral  and  octahedral 
crystals,  it  may  be  affirmed  that  sugar 
is  present  in  the  urine. 

It  is  possible  to  partially  rid  one's  self 
of  the  reducing  substances,  by  means  of 
a.  process  described  a  long  time  ago  by 
Seegen,  and  which  is  to  be  recommended 
on  account  of  its  simplicity.  The  urine 
is  filtered  through  animal  charcoal  as 
many  times  as  are  necessary  to  discolor 
it;  then  the  charcoal  is  washed  in 
distilled  water,  and  the  two  filtered  liq- 
uids— the  urine  and  the  distilled  water 
— are  treated  separately  by  Fehling's 
solution. 

The  reason  is  as  follows: — 

The  charcoal  not  only  retains  the  col- 
oring matter  and  the  uric  acid,  but  like- 
wise certain  substances,  as  yet  not  well 
known,  which  prevent  the  precipitation 
of  the  oxide  of  copper.  Therefore  we 
are  better  able  to  search  for  the  sugar 
with  the  filtered  water  than  with  the 
urine.  Furthermore,  the  charcoal  has 
retained  a  large  portion  of  the  sugar  con- 
tained in  the  urine,  and  gives  off  into 
the  distilled  water  a  larger  portion  of  the 
sugar  than  of  the  other  substances  which 
it  had  retained.  Consequently  the  re- 
duction of  Fehling's  solution  is  much 
more  easily  accomplished  by  this  water 
than  by  the  urine. 

These  are  the  advantages  of  Seegen's 
method,  by  means  of  which  the  author 
is  able  to  discover  a  one-thousandth  part 
of  sugar  in  the  urine.  Even  with  a 
smaller  proportion  there  will  be  a  reac- 
tion, but  this  will  only  become  apparent, 
says  Seegen,  after  several  minutes'  heat- 
ing.    No  other  method  surpasses  this  in 


sensitiveness,  and  it  is  most  easy  of  appli- 
cation, provided  a  perfect  animal  charcoal 
is  at  hand. 

To  summarize  what  I  have  already 
stated  in  the  beginning,  Fehling's  solu- 
tion, provided  one  knows  how  to  use 
it,  is  capable — all  statements  to  the  con- 
trary notwithstanding — of  alone  deter- 
mining the  existence  of  sugar.  The  re- 
ducing action  of  glucose  upon  the  oxide 
of  bismuth  in  the  presence  of  an  alkali 
has  also  been  resorted  to  for  a  long  time. 
This  reaction,  called  that  of  Bottiger, 
which  is  described  in  all  the  treatises  on 
urology,  is  far  from  being  valueless,  es- 
pecially when  made  use  of  with  the  modi- 
fication indicated  by  Nylander. 

Leaving  aside  several  other  reactions, 
which  have  not  come  into  general  use, 
because  they  are  not  sufficiently  accurate, 
I  pass  on  to  the  reaction  of  phenylhy- 
drazin,  described  by  Fisher,  and  em- 
ployed by  von  Jaksch  for  the  discovery 
of  glucose  in  the  urine.  This  reaction 
is  based  upon  the  property,  peculiar  to 
phenylhydrazin,  of  forming,  when  in 
combination  with  glucose,  a  crystalline 
substance  of  a  decidedly-yellow  color. 

Jaksch  obtains  this  reaction  as  follows: 
10  cubic  centimetres  of  the  urine  to  be 
tested  are  poured  into  a  tube,  adding 
three  pinches  of  the  acetate  of  soda  in 
crystals,  also  two  pinches  of  hydrochlo- 
rate  of  phenylhydrazin.  The  mixture  is 
placed  for  a  time  in  a  water-bath.  After 
it  has  cooled  a  yellow,  crystalline  deposit 
is  formed,  which,  under  the  microscope, 
appears  to  be  composed  of  fine  needles, 
some  isolated,  others  in  bunches,  and 
some  assuming  star-formations. 

It  has  been  said  that  this  reaction  is 
not  absolutely  characteristic,  and  that 
glycuronic  acid  will  also  cause  needle- 
formations;  but  Ilirschl  has  ascertained 
that  by  leaving  the  tube  one  hour  in  the 
w(itcr-l>atli  the  glycosuric  components  do 


DIABETES  MELLITUS.    DIAGNOSIS. 


449 


not  give  rise  to  a  crystalline  precipitate, 
and  Binet,  who  has  made  a  very  complete 
study  of  this  important  reaction,  consid- 
ers it  as  absolutely  reliable  with  the  fol- 
lowing slight  modifications: — 

Ten  cubic  centimetres  of  the  urine  to 
be  examined,  deprived  of  albumin,  are 
taken  and  cleared  by  means  of  a  few 
drops  of  an  acetate-of-lead  solution.  It 
is  then  filtered,  and  a  few  drops  of  acetic 
acid,  three  pinches  of  acetate  of  soda,  and 
two  of  hydrochlorate  of  phenylhydrazin 
are  added.  The  whole  is  left  in  the 
water-bath  for  one  hour.  The  tube  is 
then  allowed  to  cool,  and  on  the  follow- 
ing day  the  urine  is  examined  with  a  very 
powerful  magnifying-glass.  Under  these 
conditions  no  balls  or  granular  masses 
are  found,  but  yellow  or  silvery  crystals, 
characteristic  of  phenylglucosazone.  Ac- 
cording to  Binet,  by  proceeding  in  this 
way,  one  two-thousandths  of  sugar  is 
distinguishable — an  exceedingly  small 
proportion.  The  reaction,  which  is  abso- 
lutely correct,  is,  therefore,  an  extremely- 
sensitive  one. 

I  do  not  believe  that  fermentation  sur- 
passes it  in  this  respect.  Beer-yeast 
alone,  and  likewise  the  urine  itself,  when 
left  undisturbed,  give  rise  to  some  gas- 
bubbles.  Thus,  in  order  to  arrive  at  the 
certainty  of  the  existence  of  the  sugar, 
a  test  experiment  must  be  made.  Two 
similar  test-tubes  are  prepared,  the  sus- 
pected ■urine  is  placed  in  one,  and  normal 
urine  in  the  other,  an  equal  quantity  of 
yeast  is  added  to  each  one,  and  they  are 
left  under  the  same  conditions  during 
twenty-four  hours. 

One  thousand  specimens  of  normal 
and  pathological  urine  examined  with 
the  view  of  ascertaining  whether  traces 
of  s\igar  must  be  looked  upon  always 
as  pathological.  Using  the  phenylhy- 
drazin and  the  fermentation  tests  as  the 
most  delicate  tests  for  sugar,  58  per  cent, 
of  the  analyzed  urine  showed  no  trace 

2—29 


of  sugar;  traces  of  sugar  cannot,  there- 
fore, be  looked  upon  as  normally  pres- 
ent in  the  urine. 

Of  the  tests  which,  in  doubtful  cases, 
prevent  the  possibility  of  a  mistake,  the 
phenylhydrazin  test  must  be  cited.  The 
only  drawback  of  the  test  is  the  forma- 
tion of  crystals  similar  to  the  phenyl- 
glucosazone crystals,  if  glycuronic  acid 
be  present  in  the  urine.  However,  the 
microscopical  appearance  of  the  two  sets 
of  crystals  is  sufBciently  distinctive. 
The  phenylglucosazone  crystals  occur  in 
the  form  of  bundles  of  long  needles  and 
of  separate  needles;  the  crystals  of 
glycuronic  acid  appear  in  tlie  form  of 
rosettes,  the  needles  are  thick  and 
plump,  and  the  whole  resembles  the 
crystals  of  ammonium  uitite.  The  deli- 
cacy of  the  test  is  interfered  with  in 
albuminous  urines  and  in  urines  which 
are  concentrated  or  rich  in  urates.  A. 
Jolles  (Centralb.  f.  klin.  Med.,  Nov.  3, 
10,  '94). 

Glucose  is  not  a  normal  constituent 
of  the  urine;  high  specific  gravity  does 
not  always  indicate  the  presence  of 
sugar;  not  infrequently  concentrated 
urines  with  a  specific  gravity  of  1028  to 
1032  contain  no  sugar;  small  quantities 
of  sugar  influence  the  specific  gravity 
very  little.  Trommer's  and  Worm-JIuel- 
ler's  tests  are  confusing.  In  the  Fehling- 
Wendriner  test  results  did  not  always 
agree.  Hoppe-Seyler's  test  with  alpha- 
nitro-phenylpropionic  acid  is  not  adapted 
as  a  single  test.  Its  delicacy  lies  at 
about  0.4  per  cent.  JoUes  (Amer.  Med.- 
Surg.  Bull.,  July  5,  '95). 

In  two  clean  and  dry  test-tubes  10 
cubic  centimetres  of  normal  and  diabetic 
urine,  respectively,  are  placed;  0.5  milli- 
giamme  or  less  of  fincly-rubbed-up  gen- 
tian-violet is  then  allowed  to  drop  on 
to  the  surface  of  the  urine.  In  diabetic 
urine  the  superficial  layers  of  varying 
depth  are  colored  blue  or  violet-blue, 
and  this  color  does  not  disappear  on 
shaking.  In  normal  urine,  even  after 
shaking,  no  color,  or  only  the  faintest 
trace,  is  developed.  Merck's  gentian- 
violet  B  is  the  best.  In  low  tempera- 
tures the  reaction  is  not  so  marked. 
The  addition  of  mineral  acids  or  sugar 
to   normal   urine   will   not   lead   to    the 


450 


DIABETES  JIELUTUS.    DIAGNOSIS. 


development  of  this  color-reaction,  which 
13  really  due  to  the  presence  of  reducing 
substances  in  the  diabetic  urine.  Bremer 
(Centralb.  f.  inn.  Med.,  Apr.  2,  '9S). 

To  10  cubic  centimetres  of  the  urine 
are  added  5  cubic  centimetres  of  a  con- 
centrated solution  of  neutral  lead  ace- 
tate, and  then,  after  shaking,  5  cubic 
centimetres  of  basic  lead-acetate  solu- 
tion. When  the  whole  is  filtered,  an 
almost  clear  colorless  fluid  should  be 
obtained.  Then  equal  parts  of  the  fil- 
trate and  a  watery  solution  of  methy- 
lene-blue  (0.3  per  cent.)  are  placed  in 
two  difi'erent  test-tubes,  and  to  the  tubes 
containing  the  methylene-blue  is  added 
1  cubic  centimetre  of  a  10-per-cent. 
caustic-potash  solution  for  each  5  cubic 
centimetres,  so  as  to  make  it  strongly 
alkaline.  This  latter  tube  is  then  heated 
over  an  open  flame,  and  the  contents  of 
the  other  tube  are  poured  into  it,  and 
the  whole  boiled.  If  sugar  is  present, 
the  dark-blue  color  is  changed  to  a 
whitish  one;  the  solution  then  becomes 
transparent,  and  finally  a  pale  yellow. 
The  lowest  limit  lies  at  about  0.04  to 
0.05  per  cent,  of  sugar;  the  reaction 
with  a  urine  containing  1  in  1000  sugar 
is  slow.  Frolich  (Centralb.  f.  inn.  Med., 
Jan.  29,  '98). 

To  recapitulate,  Seegen's  method  with 
Fehling's  solution,  the  phenylhydrazin 
reaction,  and  fermentation  are  the  three 
methods  capable  of  recognizing  with  cer- 
tainty the  presence  of  a  small  quantity 
of  sugar.  The  first  is  by  far  the  most 
rapid.  The  phenylhydrazin  requires  at 
least  two  hours  and  the  fermentation 
test  twenty-four  hours. 

Nitropropiol  test:  A  tablet  is  dropped 
into  10  or  15  drops  of  urine,  diluted 
with  about  10  cubic  centimetres  of  dis- 
tilled water,  and  warmed  slightly.  If 
sugar  is  present  the  solution  turns  first 
green  and  then  blue.  If  but  a  small 
quantity  is  present,  tliis  can  be  con- 
centrated by  shaking  with  chloroform, 
as  in  the  indican  reaction.  The  reac- 
tion docs  not  occur  with  biliary  pig- 
ments, uric  acid,  albumin,  blood,  or 
phosphates.  Neither  does  it  occur  in 
the  urine   of  patients  wlio   have   been 


taking  benzoic  acid,  chloral,  carbolic 
acid,  guaiacol,  iodine,  the  salicylates, 
senna,  or  turpentine.  Gebbart  (Miln- 
ehener  med.  Woch.,  Jan.  1,  1901). 

A  new  test  for  sugar  is  to  take  about 
20  drops  of  urine  in  a  test-tube  and  add 
a  small  amount  (about  Vm  gramme)  of 
pure  hydrochloride  of  phenylhydrazin, 
about  '/;  gramme  of  crystallized  sodium 
acetate,  2  cubic  centimetres  of  water. 
This  is  heated  over  a  flame  until  it  boils, 
then  10  cubic  centimetres  of  a  10-per- 
cent, sodium-hydrate  solution  is  added, 
the  tube  being  inverted  five  or  six  times 
and  then  stood  aside.  After  a  few  sec- 
onds a  striking  reddish-violet  color 
should  make  its  appearance.  The  color 
is  seen  by  holding  the  test-tube  up  to 
the  light,  when  the  whole  fluid  should 
be  colored,  not  merely  the  deposit  upon 
the  bottom  of  the  tube.  The  color 
should  appear  within  five  minutes.  E. 
Rieglar  (Deutsche  med.  Woch.,  Jan.  17, 
1901). 

I  have  yet  to  refer  to  certain  very  rare 
cases  in  which,  although  the  urine  re- 
sponds to  Fehling's  test  and  becomes 
brown  by  the  addition  of  caustic  potash, 
it  does  not  actually  contain  sugar,  but 
instead  alcaptone.  In  these  cases  there 
is  no  polarimetric  deviation  nor  any  alco- 
holic fermentation. 

The  diabetograph  is  an  instrument  de- 
vised for  the  purpose  of  rapidly  and 
automatically  estimating  the  amount  of 
sugar  contained  in  the  urine  of  diabetic 
patients.  It  consists  of  a  glass  cylinder 
20  centimetres  in  length,  bell-shaped  at 
the  moutli,  tapering  to  the  other  ex- 
tremity, where  tliere  is  a  stop-cock. 
Figures  are  marked  along  the  tube.  The 
cylinder  is  filled  with  tlie  urine  to  be 
analyzed,  and  by  careful  management 
of  the  stopcock  allowed  to  flow  drop 
by  drop  into  a  small  glass  receptacle 
in  wliich  2  cubic  centimetres  of  Fehling's 
solution  diluted  with  six  times  its 
volume  of  distilled  water  has  been  al- 
lowed to  come  to  the  boiling-point. 
When  the  desired  reaction  is  obtained, 
the  number  opposite  the  level  of  the 
urine  in  tlie  tube  will  indicate  the 
urrioiiiil,   fif    gliii'OHi!    to    (lie    litre    of   the 


DIABETES  MELLITUS.    ETIOLOGY. 


451 


urine.      F.    Coulon    (Archives    G6n.    de   I 
M6d.,  Sept.,  1900). 

The  Diagnosis  of  Diabetes  by 
Means  of  the  Blood. — Bremer,  as  we 
have  already  mentioned  above,  has  found 
that  the  red  corpuscles  of  diabetic  blood 
cannot  be  stained  with  aniline  colors  in 
the  same  way  as  the  blood-corpuscles  of 
the  normal  blood.  The  latter  are  dis- 
tinctly acidophilous,  while  in  the  dia- 
betic blood  they  become  basophilous; 
they  no  longer  take  up  eosin,  the  pre- 
ferred color  of  the  normal  blood-cor- 
puscles. 

This  reaction,  which  Bremer  has  sub- 
jected to  several  variations,  is  of  great 
importance  in  cases  in  which  a  diabetic 
patient,  who  has  no  actual  sugar  in  his 
urine,  wishes  to  conceal  his  disease  from 
the  physician  of  an  insurance  company. 
It  is  important  to  know,  however,  that 
this  reaction  is,  as  Bremer  ha's  stated, 
independent  of  the  glucose,  not  pathog- 
nomonic of  diabetes.  It  may,  also,  take 
place  in  the  corpuscles  of  leukemic  blood. 
(L6pine  and  Lyonnet.)  See  Complica- 
tions. 

Bremer's  test  of  the  blood  of  diabetics 
modified  by  staining  two  minutes  in  a 
2-per-cent.  methylene-blue  solution  and 
then  ten  seconds  in  a  25-per-cent.  eosin 
solution.  This  reaction  was  obtained  in 
the  blood  in  all  cases  of  diabetics  whose 
urine  contained  more  than  2  per  cent,  of 
sugar.  Loewy  (Fort,  der  Jted.,  Mar., 
'98). 

Reaction  of  diabetic  blood  may  be  ob- 
tained as  follows:  4  cubic  millimetres 
of  water  arc  placed  in  the  bottom  of  a 
small,  narrow,  test-tube.  To  this  are 
added  20  cubic  millimetres  of  blood,  1 
cubic  centimetre  of  a  watery  solution  of 
methylene-blue  (1  to  GOOO)  and  40  cubic 
millimetres  of  liquor  potassoo.  The  test- 
tube  is  then  placed  in  boiling  water  for 
four  minutes,  at  the  end  of  which  time, 
if  the  blood  is  diabetic,  the  blue  color  of 
the  mixture  will  have  disappeared  and  a 
dirty-yellow  color  will  liave  taken  its 
place.     The  reaction  has  been  obtained 


in   all   of   forty-three   cases   of   diabetes. 

K.  T.  Williamson  (Lancet,  Aug.  4,  1900). 
Etiology. — Statistics  referring  to  thou- 
sands of  cases  show  that  diabetes  is  most 
prevalent  between  the  ages  of  50  and  60 
years. 

Age  is  usually  regarded  as  a  factor  in 
the  etiology,  and,  according  to  a  per- 
sonal analysis  of  2115  cases,  the  period 
of  its  greatest  frequency  extends  between 
30  and  CO  years  of  life  (the  greatest 
number  fall  between  50  and  00  of  any 
of  the  decades).  Diabetes  mellitus  pre- 
vails to  a  much  greater  extent  in  some 
localities  than  in  others;  for  example, 
in  Malta  it  is  a  scourge  of  greater  sever- 
ity even  than  tuberculosis  is  in  Germany. 
It  is  common  in  Sweden,  and  very  fre- 
quent among  Jews,  wherever  they  may 
live.  Schmitz  (Berliner  klin.  Woch., 
July  6,  '91). 

It  is  probable,  however,  in  view  of  the 
difficulty  frequently  experienced  in  de- 
termining the  exact  onset  of  the  disease, 
that  it  often  begins  before  the  age  of  50. 
The  disease  is  relatively  rare  in  child- 
hood. No  cases  were  known  in  which 
the  disease  existed  in  early  childhood 
until  very  recently  (during  the  past  few 
years),  when  several  cases  have  been  pub- 
lished. 

One  hundred  and  seventeen  cases  in 
children  collected.  The  disease  is  not 
near  so  rare  in  children  as  has  been 
commonly  supposed.  As  to  sex,  of  the 
117  cases,  47  were  females,  31  males; 
of  the  remainder,  the  sex  was  not  de- 
terminable. The  proportion  of  males  to 
females  was  5  to  3.  As  to  the  age  itself, 
G  were  found  under  1  year,  1  seeming 
to  be  bom  with  it,  as  it  was  noted  a 
few  days  after  birth;  7  were  over  1 
year,  3  over  2  years,  "  over  3  years,  6 
over  4  years,  5  over  5  years,  )  over  6 
years,  0  over  7  years,  and  2  cases  had 
completed  8  years;  8  were  9  years  old, 
0  were  10  years,  9  were  11  years,  8  were 
12  years,  0  were  13  years,  5  were  14 
years.  4  were  15  years  old.  Of  the  re- 
maining 28  the  age  was  not  given.  The 
children  appeared  generally  of  the  better 
class.    As  to  the  etiology,  heredity  was 


452 


DIABETES  MELLTTUS.    ETIOLOGY. 


conspicuous,  since  the  parents  were  often 
diabetic.  Nest  to  heredity,  previously- 
existing  disease  was  found;  the  most  fre- 
quent cause  was  notably  gastric  catarrh. 
C.  Stern  (Archiv  f.  Kinderh.,  B.  11,  H. 
2,  'S9). 

The  urine  of  50  nurslings  between  the 
age  of  1  day  and  4  weeks  examined. 
This  number  included  24  healthy  chil- 
dren, 1  premature  child,  1  case  of  hy- 
drocephalus, 14  cases  of  acute  and 
chronic  gastro-enteritis,  and  10  cases  of 
other  forms  of  dyspepsia.  Among  the 
50  cases  the  urine  of  10  caused  a  reduc- 
tion of  Trommer's  test  with  cupric  sul- 
phate. In  2  cases  the  results  were  con- 
firmed by  observations  made  with  the 
polarimeter.  These  10  cases  included  7 
of  aggravated  gastro-enteritis  which 
terminated  fatally,  and  3  of  mild  dys- 
pepsia. Grosz  (Pester  Med.-Chirurgische 
Presse,  No.  37, '92). 

It  appears  upon  a  study  of  108  cases 
of  infantile  diabetes  that  children  of 
both  sexes  seem  to  be  affected  in  an 
equal  proportion,  and  that  the  disease 
is  most  frequently  observed  about  the 
age  of  5  years.  As  a  cause,  traumatism 
was  found  in  11  cases;  dentition,  chill, 
excesses  of  various  kinds,  rapid  growth, 
insufficient  food,  violent  emotion,  or  sor- 
row in  others.  Wcgeli  (Archiv  f.  Kin- 
derh., B.  19,  H.  1, '95). 

The    disease    is    exceedingly    fatal    in 
young   children.     "SVhenever   a    child    is 
brought  to  the  physician  with   a  rapid 
atrophy  he  should  examine  the  urine  for 
sugar.    H.  D.  Chapin  (Jour.  Amer.  Med. 
Assoc,  Sept.  15,  1900). 
Men  are  much  more  likely  to  be  at- 
tacked  by   diabetes   than   women.     In 
childhood  sex  has  no  influence. 

Out  of  1004  cases  of  diabetes,  837— 
or  83.37  per  cent.— were  males,  and  107 
—or  16.C3  per  cent.- were  females.  A. 
Cantani  (Deut.  med.  Woch.,  Noa.  12  to 
14, '89). 

Tlie  proportion  of  males  and  females 
in  tlie  white  race  who  suffer  from  dia- 
betes is  about  3  to  2.  In  children,  how- 
ever, the  ratio  is  not  the  same;  girls 
have  it  more  frequently  than  boys.  In 
the  colored  race  the  cases  occur  more 
frequently     in     women    than     in     men. 


Futcher    (Johns    Hopkins    Hosp.    Bull., 
Feb.,  '9S). 
The  frequency  of  diabetes  varies  very 
much  in  diiferent  countries. 

In   Danish   cities   the   mortality  from 
this  disease  has  almost  quadrupled  itself 
during  the  last  thirty  years.     In  Paris, 
between  the  years  of  1865  and  1873,  only 
2   to   3   in  each    100,000   died   annually 
from    diabetes.     By    1892    the   numbers 
had  risen  to  13  in  100,000.    The  disease 
is  exceedingly  common  in  India,  in  Rus- 
sia it  is  very  uncommon,  and  in  Nor- 
mandy it  is  wide-spread.     L6pine   (Rev. 
de  Mfd.,  '96). 
In  the  absence  of  sufficiently-reliable 
statistics,  it  is  preferable  to  abstain  from 
giving  any  figures.    In  the  same  country 
different  races  are  very  unequally  af- 
fected, and  on  this  point,  also,  it  is  neces- 
sary to  await  further  researches.    A  fact 
which  may  be  positively  stated  at  pres- 
ent is  the  relative  frequency  of  diabetes 

in  the  Jewish  race. 

In  Frankfort-on-the-Main  171  persons 
died  from  diabetes  during  a  period  of 
nineteen  years.  Of  156  of  these  cases,  51 
were  Jews  and  105  belonged  to  other 
denominations.  The  mortality  from  dia- 
betes is  six  times  as  great  among  Jews 
as  in  other  religions.  Wallach  (Deut. 
med.  Woch.,  Aug.  10,  '93). 

Two  hundred  and  two  deaths  from  dia- 
betes in  the  city  of  New  York  during 
1899  shows  that  the  greatest  mortality 
occurred  between  the  fifty-fifth  and  sixty- 
fifth  years,  and  diminished  rapidly  toward 
the  end  and  beginning  of  life.  Fifly- 
seven  were  born  in  Germany,  51  in 
United  States,  and  37  in  Ireland.  At 
least  54,  or  25  per  cent.,  were  Jews  and 
51  were  Irish.  The  potent  influence  i» 
believed  to  be  the  breeding  in  and  in, 
to  which  the  Jewish  and  Irish  races  still 
adhere.  Coma  was  direct  cause  of  death 
in  00  cases.  Gangrene  was  the  most  fre- 
quent complication,  and  appeared  in  the 
foot  or  leg  in  32  cases.  H.  Stern  (Mod. 
Record,  Nov.  17,  1900). 
Diabetes  is  frequently  hereditary,  inas- 
much as  several  members  of  one  and  the 
same  family  are  frnqiiently  affected  with 


DIABETES  MELLITUS.     ETIOLOGY. 


453 


the  disease;   Lut  the  heredity  is  seldom 
direct. 

The  diabetic  predisposition  is  heredi- 
tary. In  998  cases  out  of  2115  it  was  dis- 
covered positively  that  there  were,  or 
had  been,  1  or  2  cases  of  diabetes  among 
their  blood-relations,  and  in  some  cases 
more.  Schmitz  (Berliner  klin.  Woch., 
July  0,  '91). 

In  June,  1900,  a  man,  aged  48  years, 
consulted  the  writer  for  symptoms 
which  proved  to  be  those  of  diabetes 
mellitus.  The  disease  had  followed  an 
attack  of  influenza  contracted  in  the 
previous  February.  The  patient's 
father  had  died  of  diabetes  also.  Sev- 
eral months  later  the  writer  was  con- 
sulted by  the  patient's  wife,  a  wo- 
man aged  40  years.  She  was  found  to 
have  exophthalmic  goitre.  The  exam- 
ination of  the  urine  showed  a  large 
amount  of  sugar  present.  The  writer 
considers  this  a  typical  case  of  conjugal 
diahetes,  although  some  objection  might 
be  taken  to  this  opinion,  owing  to  the 
not  infrequent  occurrence  of  glycosuria 
in  exophthalmic  goitre.  He  states  that 
he  observed  four  cases  of  conjugal  dia- 
betes in  his  practice  during  the  year 
1903,  and  does  not  believe  that  the  con- 
dition is  extremely  rare. 

At  the  beginning  of  this  year  the 
mother  of  the  first  patient,  aged  66 
years,  came  under  treatment  for  a 
phlegmon  on  the  right  hand,  which  de- 
veloped very  rapidly  after  being  pricked 
with  a  needle.  The  examination  of  this 
patient's  urine  also  showed  abundance 
of  sugar.     She  lived  with  her  son. 

In  this  family  the  patient,  his  mother, 
and    his    wife    had    diabetes,    and    his 
father  died  of  the  disease.     Tlie  writer 
lays  down  the  following  axiom:    If  one 
discovers    diabetes    in    one    or    several 
members  of  a  family,  the  urine  of  all 
the  other  members  should  be  examined 
for  sugar,  eapecially  if  the  various  mem- 
bers live  together.    Martinet  (La  Presse 
M6d.,  Feb.  10,  1904). 
It  has  been  justly  remarked  that  these 
diabetic  families  are  tainted  with  the 
uric-acid  diathesis,  and  that  obesity,  gout, 
and  neuropathic  aflcctions  exist  in  extra- 
ordinary   frequency    in    such    families. 


Frequently  obesity  and  diabetes  co-exist 
in  the  same  person.  A  too  exclusively- 
starchy  diet  and  the  abuse  of  wine  and 
ciders  are  predisposing  causes  of  dia- 
betes. 

In  200  cases  there  were  found  4  in- 
temperate, 107  temperate,  89  total  ab- 
stainers, 09  opium  habituCs.  Mitra 
(Indian  Med.  Record,  June  1,  '95). 

In  GOT  persons  engaged  in  manual 
labor  or  requiring  great  muscular  and 
respiratory  activity,  no  sugar  was  found 
in  any  case;  in  100  persons  engaged  in 
intense  intellectual  work,  sugar  was 
found  in  10.  Worms  (Bull,  de  I'Acad. 
de  Med.  de  Paris,  July  29,  '95). 

Diabetes  appears  more  frequently  in 
March,  April,  July,  and  November;  in- 
creased mortality  in  winter,  but  not  in 
relation  with  average  temperature.  Davis 
(Amer.  Jour,  of  the  Med.  Sciences,  July, 
'95). 

The  increase  of  diabetes  is  much  more 
pronounced  among  the  wealthy  classes 
than  among  the  poor,  the  average  in 
the  poorer  parts  of  the  city  being  only 
7  to  9  in  100,000,  while  in  the  wealthy 
quarters  the  average  is  IG  to  20.  Ber- 
tillon  (Editorial,  Modem  Med.  and  Bact. 
Rev.,  Apr.,  '97). 

The  causes  which  we  have  so  far  men- 
tioned are  predisposing  causes. 

As  to  eiRcient  causes  of  diabetes,  acute 
infectious  diseases  cannot  be  considered 
in  this  categor)',  for  the  affection  does 
not  come  on  after  typhoid  fever,  eruptive 
fevers,  etc.  With  regard  to  malaria,  sev- 
eral French  physicians  have  noted  a 
temporary  glycosuria  after  attacks  of  in- 
termittent fever;  but  in  malarial  coun- 
tries true  diabetes  does  not  appear  to  be 
any  more  common  than  elsewhere. 

The  question  of  sj'philis  will  be  re- 
ferred to  later. 

The  part  played  by  contagion  in  dia- 
betes is,  so  far,  not  based  upon  any  very 
exact  observations.  The  occurrence,  said 
to  be  quite  frequent,  of  diabetes  in  hus- 
band and  wife,  has  been  a  mooted  ques- 
tion. 


454 


DIABETES  MELLITUS.    ETIOLOGY. 


Man  aud  wife  may  both  be  diabetic. 
From  an  analysis  of  2320  cases,  26  ex- 
amples of  such  occurrence  have  been 
accumulated.  Quite  healthy  persons, 
■without  hereditary  predisposition,  may 
become  suddenly  diabetic  after  attend- 
ing to  a  diabetic  for  a  time,  living  in 
the  same  room,  sleeping  with  and  espe- 
cially kissing  him  often.  In  the  light 
of  these  data,  embodying  somewhat  over 
1  per  cent,  of  several  thousand  cases, 
the  possibility  of  an  infectious  nature 
in  diabetes  mellitus  is  strongly  sug- 
gested. Schmitz  (Berliner  klin.  Woch., 
May  19,  '90). 

Twenty-six  examples  recorded  where 
husband  and  wife  both  suffered  from  dia- 
betes. These  were  examples  chiefly  of 
married  females  who  had  become  sud- 
denly diabetic  after  nursing  a  diabetic 
husband.  There  was  no  indication  of 
hereditary  predisposition.  No  family 
relationship  between  the  patients,  no 
excess  of  sugar  taken  in  the  food,  and 
the  patients  had  not  suffered  from  gout. 
The  question  raised  of  the  possibility  of 
contagion  or  transmission  of  the  disease. 

The  numerical  relation  between  dia- 
betic mamcd  couples  and  other  diabetic 
cases  is  shown  in  the  following  table: — 


Betz  

Hcrtzka  . 
LecorchO 
Schmitz  . 
Seegen  . . 
KUlz 


Married 
Diabetics. 

Total 
Diabetics 

1 

31 

1 

86 

G 

114 

26 

2320 

3 

938 

10 

900 

Totals 


47 


43.89 


or  1:03'/,  or  1.08  per  cent.  B.  Oppler 
and  C.  KUlz  (Berliner  klin.  Woch.,  Nos. 
20  and  27,  '90). 

Among  770  cases  of  diabetes  observed 
there  have  been  9  instances  of  man  and 
wife  suffering  from  the  disease:  1.19  per 
cent.  When  all  the  cases  arc  excluded 
in  which  there  is  a  family  history  of  the 
diseaBe,  or  a  history  of  any  of  the  well- 
known  etiological  antecedents,  the  cases 
remaining  are  so  few  that  it  seems  prob- 
able that  the  occurrence  is  accidental, 
or  tliat  both  man  and  wife  have  been 
Bubjcctcd  to  the  same  anlcccdentB.     II. 


Senator   (Berliner  klin.  Woch.,  July  27, 
'96). 

In  a  series  of  5000  cases  1.8  per  cent, 
of  conjugal  diabetes  found.  The  facts 
thus  far  published  do  not  shed  much 
light  on  the  two  theories  of  causation 
now  held,  viz.:  (1)  that  the  ordinarily- 
accepted  causes  of  diabetes  are  active  in 
both  husband  and  wife,  aud  (2)  that  the 
disease  is  contagious.  Cases  have  been 
reported  with  almost  conclusive  evidence 
of  contagion,  but  the  nature  of  the  con- 
tagion and  how  it  is  conveyed  are  mys- 
teries.   Schram  (Med.  News,  Jan.  1,  '93). 

This  coincidence,  if  it  actually  is  of 
frequent  occurrence,  would  be  an  argu- 
ment in  favor  of  contagion.  The  ques- 
tion is  now  being  studied. 

Nervous  affections  are  certain  causes 
of  diabetes.  The  disease  is  often  met 
with  in  people  who  have  suffered  from 
much  anxiety  or  worriment. 

Diabetes  should  be  classed  among  the 
neuroses;  its  varied  phenomena  result 
by  reflexes  from  the  nervous  system. 
The  disease  obviously  arises  in  the 
sympathetic  chain  which  controls  the 
secretory  functions  of  the  kidneys.  J. 
Blake  White  (Amer.  Medico-Surg.  Bull., 
'95). 

A   number    of   cases   are   reported   in 
the  literature  in  which  diabetes  has  fol- 
lowed   a    shock    or    psychical    trauma. 
For  the  most  pai-t,  these  cases  have  not 
been   severe,   but   in   the   two   reported 
by  the  author  both  died.    Lorand    (St. 
Petcrsburger    med.    Wochen.,    May    31 
(June  13),  1903). 
Diabetes  also  occurs  very  frequently 
where  there  has  been  traumatism  of  the 
head.    According  to  certain  statistics,  20 
per  cent,  of  all  cases  of  diabetes  are  due 
to  this  cause.     It  is  possible  that  this 
proportion  may  bo  exaggerated,  but  I 
am  willing  to  admit  that  there  is  surely 
one  case  of  traumatic  diabetes  in  thirty 
diabetic  patients. 

The  lra\iniati8ma  most  often  followed 
by  diabetes  are  those  affecting  the  head 
(25  in  4.'))  ;  Homctiiucs  also  those  affect- 
ing the  vertebral  coliiiiin.     Oerebral  dia- 


DIABETES  IHELLITUS.    ETIOLOGY. 


455 


turbance  mentioned  twelve  times.  Sugar 
does  not  always  appear  in  the  urine  im- 
mediately after  traumatism;  if  the  dia- 
betes succeeds  rapidly  to  traumatism, 
it  is  almost  always  mild;  on  the  con- 
trary, almost  all  the  uncured  cases  of 
traumatic  diabetes  begin  late.  Progress 
is  at  times  rapid;  radical  cures  have 
been  observed  fairly  often  (14  cases  out 
of  45),  but  they  seldom  take  place  where 
diabetes  has  persisted  more  than  six 
months  or  a  year.  Bemstein-Kohan 
(These  de  Paris,  '91). 

Review  of  212  cases  of  traumatism  of 
the  head  admitted  into  the  Boston  City 
Hospital  within  thirteen  months.  Ranged 
in  five  classes:   (1)  wounds  of  the  scalp; 

(2)  wounds  with  denudation  of  the  bone; 

(3)  commotion,  including  cases  followed 
by  loss  of  consciousness,  but  without 
fracture;  (4)  fracture  of  the  vault;  (5) 
fracture  of  the  base.  Of  the  first  class 
there  were  84  cases,  5  of  wliich,  or  6  per 
cent.,  presented  glycosuria;  in  the  sec- 
ond class,  43  cases,  4  with  glycosuria, — 
9  per  cent.;  third  class,  40  cases,  1  with 
glycosuria, — 2.5  per  cent.;  fourth  class, 
24  cases,  5  with  glycosuria, — 20.8  per 
cent.;  fifth  class,  21  cases,  5  with  gly- 
cosuria,— 23.8  per  cent.  In  all,  20  cases 
of  glycosuria  in  212  cases.  F.  A.  Hig- 
gins  and  J.  B.  Ogden  (Boston  Med.  and 
Surg.  Jour.,  Feb.  28,  '95). 

Since  the  time  of  Claude  Bernard  we 
are  aware  of  the  fact  that  lesions  of  the 
floor  of  the  fourth  ventricle  are  particu- 
larl)'  liable  to  give  rise  to  diabetes.  Sev- 
eral cases  have  been  observed  in  man. 
Lesions  in  various  parts  of  the  encepha- 
lon  may  bring  about  the  same  result. 
It  is  extremely  probable  that  syphilis  is 
not  a  cause  of  diabetes,  except  through 
the  influence  of  diffuse  lesions  of  the 
nerve-centres.  There  is  conseq\iently  no 
syphilitic  diabetes,  but  a  diabetes  de- 
pendent upon  cerebral  lesions,  whether 
due  to  syphilis  or  any  other  cause. 

Out  of  twenty-seven  records  of  exam- 
ination of  the  brain  in  cases  of  diabetes 
mellitus,  the  organ  normal  in  but  five 
instances,  the  abnormalities  consisting 
most    frequently    of    ccdematous    brains 


with  thickenings  of  the  membranes. 
Less  frequently  the  organ  was  ansemie, 
cystic,  particularly  in  the  frontal  lobes, 
in  the  pons,  and  in  the  medulla.  Care- 
ful examination  with  the  microscopB 
failed  to  indicate  any  histological 
clianges,  except  in  one  instance  where 
the  capillaries  of  the  vagus  nucleus 
seemed  to  be  abnormally  numerous  and 
full  of  blood.  Saundby  (Jled.  Chron- 
icle, Jan.,  '90). 

Two  cases  of  diabetes,  in  which 
changes  were  found  in  the  spinal  cord. 

In  the  first  case  on  naked-eye  exam- 
ination of  the  spinal  cord,  after  harden- 
ing in  Jliiller's  fluid,  degeneration  was 
found  in  the  posterior  columns.  This 
was  most  marked  in  the  cervical  and 
lumbar  enlargements.  In  the  lower 
cervical  and  dorsal  regions  the  lesion 
was  confined  to  Goll's  columns;  above 
and  below  it  extended  laterally  into 
Burdach's  columns.  The  sacral  region 
was  unalTected.  In  the  lower  dorsal 
region  the  right  posterior  column  was 
distinctly  more  markedly  affected. 

In  the  second  case  degeneration  of  the 
posterior  columns  was  also  found.  It 
was  limited  to  Goll's  columns  in  the 
upper  cervical  region.  In  the  lower 
cervical  region  it  spread  to  Burdach's 
columns,  and  was  most  extensive  in  the 
lower  cer\'ical  and  middle  dorsal  regions. 
Below  the  lumbar  enlargement  the  de- 
generation ceased. 

The  spinal  changes  regarded  as  the 
result  of  the  action  of  some  toxic  sub- 
stance in  the  blood  of  diabetic  patients. 
Similar  changes  have  been  found  in  the 
posterior  columns  of  the  spinal  cord  in 
pernicious  anoemia,  leucocytha:mia,  Ad- 
dison's disease,  etc.  E.  Kalmus  (Zeit.  f. 
klin.  Med.,  B.  30,  H.  5,  G). 

Relationship  between  diabetes  mellitus 
and  epilepsy.  Cases  in  which  the  dia- 
betes is  the  cause  of  the  epileptic  attacks 
may  be  divided  into  two  categories,  ac- 
cording as  the  attacks  are  due  to  cere- 
bral lesions  or  to  disturbance  in  the 
intra-organic  exoliange  consecutive  to 
the  glycosuria.  Cases  belonging  to  the 
former  group  are  rare.  In  the  cases  of 
epilepsy  due  to  diabetes  the  convulsive 
spasms  are  determined  by  toxic  products 
of  intra-organic  exchange,  and  take  more 


456 


DIABETES  ilELLlTUS.    ETIOLOGY. 


or  less  the  form  of  coma.  The  aceto- 
nsemic  diabetic  epilepsy  rapidly  leads  to 
fatal  coma,  but  when  it  develops  in  a 
chronic  and  intermittent  manner  is  said 
to  determine  epileptic  seizures.  The 
cases  in  which  diabetes  seems  to  depend 
upon  epilepsy  are  divisible  into  two 
clinical  varieties:  those  in  which  the 
elimination  of  sugar  merely  follows  the 
convulsive  attack — these  have  rarely 
been  found;  and  those  in  which  the 
glycosuria  is  a  more  or  less  constant 
accessory  symptom  of  the  epilepsy.  The 
cases  in  which  diabetes  and  epilepsy  ap- 
pear simultaneously  are  of  two  kinds: 
1.  Epilepsy  often  alternates  with  dia- 
betes and  mental  disorders  in  neuro- 
pathic families,  and  it  would,  therefore, 
not  be  a  matter  of  surprise  to  find  the 
two  conditions  present  in  one  person  of 
such  a  family.  2.  There  may  be  a  pre- 
disposing cause  of  both  in  the  same  sub- 
ject. 

A  case  belonging  to  this  latter  class. 
The  patient  had  an  apoplectic  stroke 
resulting  from  ischsemia  of  the  left 
hemisphere  due  to  a  cardiac  lesion. 
There  was  aphasia  and  pollakiuria,  but 
no  polj'dipsia,  polyphagia,  nor  polyuria. 
Some  months  later  epileptic  seizures, 
with  complete  loss  of  consciousness  and 
convulsions  in  the  previously-paralyzed 
half  of  the  body,  supervened.  Ebstein 
(Sera.  Mfd.,  May  22,  '96). 

Twelve  hundred  and  fifty  cases  studied 
in  tlie  psychiatric  clinic  at  Leipzig  with 
regard  to  presence  of  sugar  in  the 
urine,  with  positive  results  in  thirty 
cases.  The  -cases  were  divided  into  two 
groups:  those  of  chronic  diabetes,  which 
was  usually  associated  with  chronic 
brain  disease  of  the  type  of  dementia, 
and  those  of  transitoi-y  glycosuria, 
usually  associated  with  acute  forms 
of  insanity,  particularly  of  a  maniacal 
type.  Often  the  excitement  preceded 
the  appearance  of  sugar  in  the  urine. 
Four  possibilities  may  be  considered: 
(1)  the  glycosuria  may  be  merely 
an  accidental  complication  of  the  men- 
tal disturbance;  (2)  diabetes  may  be 
the  result  of  insanity,  (3)  or  it  may  be 
tlie  cause,  (4)  or  the  two  conditions 
may  be  the  result  of  some  common  cause. 
The  second  HometimcH  occuth  because  ex- 


cessive emotional  disturbances  have  been 

known  to  produce  diabetes.    E.  Lauden- 

heimer    (Berliner  klin.  Woch.,  May  23, 

•9S). 

The  pancreas  is  veiy  frequently  found 

altered  in  diabetic  subjects;    sometimes 

it  is  simply  atrophied,  sometimes  slightly 

indurated,  and,  under  the  microscope, 

periglandular  sclerotic  lesions  have  been 

noticed.     There  are  some  rare  cases  in 

which  the  tissue  of  this  organ  is  almost 

entirely  destroyed  in  consequence  of  the 

presence  of  calculi. 

Results  of  an  examination,  niacro- 
scopical  and  microscopical,  of  the  pan- 
creas in  23  consecutive  cases  of  diabetes 
mellitus.  In  8  cases  the  pancreas  was 
found  to  present  a  nornuxl  appearance 
both  niacroscopically  and  microscopic- 
ally; and  in  4  more  there  was  atrophy, 
but  not  more  than  could  be  accounted 
for  by  the  general  wasting.  In  5  cases 
there  was  atrophy  more  or  less  marked, 
and  out  of  proportion  to  the  general 
wasting;  and  in  one  of  these  the  atrophy 
of  the  gland  was  so  extreme  that  the 
pancreas  weighed  less  than  one-fourth 
ounce.  In  4  cases  cirrhosis  of  the  pan- 
creas was  present,  and  in  2  of  these 
the  changes  were  marked.  In  one  case 
cancer  of  the  pancreas  was  present,  and 
in  one  the  gland  had  undergone  ex- 
tensive fatty  degeneration. 

Results  of  the  investigation  of  54  cases 
of  diabetes.  In  40  of  these  the  pancreas 
was  found  to  be  diseased,  and  in  30  the 
lesion  was  a  simple  atrophy.  In  3  others 
fibrous  induration  was  present,  and  in  1 
case  the  pancreas  was  cystic.  In  8  cases 
out  of  the  54  the  pancreas  was  normal, 
and  in  0  there  was  no  record  as  to  the 
state  of  the  gland. 

The  atrophy  of  the  pancreas  in  dia- 
betes dill'crs  from  the  simple  atrophy 
accompanying  general  wasting  in  the 
fact  that  in  the  diabetic  pancreas  the 
stroma  of  tlie  gland  is  not  only  not 
wasted,  but  tlie  pancreas  shows  signs 
of  an  interstitial  inllamiiiation,  and  the 
stroma  occupies  spaces  left  by  the  atro- 
phy of  the  parenchyma  of  the  gland. 
Ilanscmann  (Med.  Chronicle,  May,  '97). 
In    70   i)fr   cent,   of   diabetic   patients 


DIABETES  ]SIELLITUS.    ETIOLOGY. 


457 


some  alterations  in  the  pancreas  were 
found.  Of  special  interest  in  this  con- 
nection is  a  lipomatosis  of  the  pancreas, 
which  may  exist  either  in  connection 
with  tlie  general  excess  of  fat,  or,  on 
the  other  hand,  may  be  found  in  lean 
subjects.  liansemann  (Med.  News,  Jan. 
22,  '98). 

Pancreatic  diabetes  is  always  grave. 
In  view  of  data  recently  furnished  by 
experimental  pathology,  there  is  no 
possible  doubt  as  to  the  pathogenesis  of 
the  diabetes  in  this  case:  it  is  evidently 
due  to  the  suppression  of  the  secretions 
of  the  pancreas. 

Diabetes  never  fails  to  appear  after 
complete  removal  of  the  pancreas,  if  the 
animals  live  a  sufficient  time  after  the 
operation.  This  statement  is  founded  on 
fifty-five  experiments  made  on  dogs. 
Minkowski  (Berliner  klin.  Woch.,  1092, 
No.  20,  '92). 

Coincidence  of  disease  of  pancreas  and 
diabetes  occurs  more  frequently  than 
diabetes  alone  or  pancreatic  disease 
alone,  and  oftener  than  these  two  com- 
bined. Commonest  disease  of  pancreas 
found  in  diabetes  is  an  atrophy  which 
differs  from  atrophy  as  the  result  of 
diabetes  or  of  cachexias;  comparable 
with  certain  forms  of  contracted  kidney. 
Hansemann  (Zeit.  f.  klin.  Med.,  B.  20, 
'95). 

Extirpation  of  pancreas  of  two  dogs, 
leaving  Vo  to  V»  of  organ;  animals  be- 
came diabetic:  one  4  and  the  other  13 
months  after.  Sandmeyer  (Zeit.  f.  Biol., 
B.  31,  p.  12,  '95). 

Eels  survived  operation  of  removal  of 
pancreas  7  to  12  days;  7  out  of  11 
showed  no  sugar  in  urine;  2  of  them 
did.  Former,  perhaps,  retained  pan- 
creatic remnants.  Caparelli  (Archives 
Italiennes  de  Biol.,  vol.  xxi,  p.  390,  '95). 
Extirpation  of  pancreas  of  19  ducks 
and  5  carnivorous  birds;  4  ducks. showed 
slight  glycosuria;  3  carnivorous  birds 
manifestly  glycosuric  until  death.  Wein- 
traub  (Archiv  f.  cxpcrimcntelle  Path.  u. 
Pharm.,  B.  34,  p.  308,  '95). 

The  existence  of  pancreatic  diabetes 
is  established,  but  disease  of  the  pan- 


creas does  not  necessarily  cause  diabetes. 
Of  29  cases  from  the  Massachusetts  Gen- 
eral Hospital  that  showed  lesions  of  the 
pancreas,  glycosuria  was  found  in  but 
2,  although  in  12  cases  there  were  no 
records  of  tests  for  sugar.  Fatty  stools 
are  usually  absent  in  cases  of  diabetes, 
and  there  is  no  record  of  their  occurrence 
in  100  cases  treated  in  the  Massachusetts 
Hospital.  R.  H.  Fitz  (Yale  Med.  Jour., 
Mar.,  '98). 

The  specific  element  of  the  pancreas 
which  controls  carbohydrate  metabo- 
lism is  not  the  secreting  parenchyma, 
but  the  groups  of  cells  known  as  the 
interacinar,  or  islands  of  Langerhans, 
which  are  independent  of  the  secret- 
ing parenchyma,  having  no  connection 
with  the  excretory  duct.  Fifty  to  60 
per  cent,  of  all  cases  of  diabetes  show 
destruction  or  marked  changes  in  the 
interacinar  islands,  accompan3ing  es- 
pecially interacinar  pancreatitis,  hepatic 
cirrhosis,  haemochromatosis ;  also  espe- 
cially prone  are  these  islands  to  hyaline 
degeneration,  often  unaccompanied  by 
any  marked  changes  in  the  secreting 
parenchyma.  For  the  remainder  of 
cases  of  diabetes,  those  which  show  no 
pancreatic  change,  no  adequate  explana- 
tion of  their  etiology  can  at  present  be 
offered.  G.  F.  Zinninger  (Cincinnati 
LancetClinie,  Aug.  13,  1904). 

In  the  cases  where  the  lesion  of  the 
pancreas  is  a  minor  one  (slight  indura- 
tion, slight  atrophy,  etc.)  it  is  not  neces- 
sary to  regard  this  slight  lesion  as  the 
cause  of  the  diabetes,  for  this  disease  is 
often  accompanied  by  a  generalized  en- 
darteritis,— a  cause  of  sclerosis;  or  some- 
times the  diabetic  cachexia  engenders 
fatty  degenerations.  Contrary  to  the 
opinion  held  about  half  a  century  ago, 
experimental  physiology  has  demon- 
strated that  hepatic  lesions  are  not  a 
cause  of  true  diabetes.  Tliey  may,  at 
most,  cause  an  alimentary  glycosuria. 

Extirpation  of  liver  prevents  ablation 

of  pancreas  to  cause  diabetes  in  the  dog. 

Marcuse    (Zeit.  f.   klin.  Med.,  B.  26,  p. 

225,  '94). 

A  patient,  aged  48  years,  who,  in  1887, 


458 


DIABETES  MELLITUS.    PATHOGENESIS.    DUKATION. 


suffered  an  attack  of  jaundice  lasting 
sis  or  eight  weeks.  The  following  year 
sugar  was  discovered  in  his  urine,  to 
the  extent  of  1 '/.  to  2  per  cent.  Dur- 
ing an  annually-repeated  "Carlsbad  cure" 
the  sugar  disappeared  from  his  urine, 
but  after  1S92  it  was  continually  pres- 
ent. In  1S93  icterus  reappeared,  and 
there  developed  ascites,  (Edema  of  the 
legs,  dyspnoea,  and  wasting.  The  liver 
and  spleen  were  much  enlarged.  Ascitic 
fluid  was  withdrawn  four  times  in  all. 
After  the  last  puncture  the  fluid  did 
again  collect.  The  amount  of  fluid  in- 
gested was  at  first  greater  than  that 
eliminated,  but  eight  weeks  after  the 
last  puncture  this  relation  was  reversed. 
With  the  excessive  excretion  of  urine  the 
ascites  and  (edema  disappeared.  The  pa- 
tient increased  in  weight  and  gained 
strength,  the  jaundice  disappeared,  and 
the  liver  decreased  in  size.  The  patient 
remained  for  a  long  time  in  good  health, 
then  albumin  appeared  in  the  urine  and 
(Edema  of  the  feet.  During  the  per- 
sistence of  the  ascites  the  sugar  disap- 
peared from  the  urine,  to  return  again 
as  soon  as  the  ascites  was  gone.  After 
two  and  a  half  years  of  good  health  the 
patient  died.  The  necropsy  revealed 
cirrhosis  of  the  liver  with  some  con- 
traction; tubercles  in  lung,  pleura,  and 
peritoneum;  diabetic  kidney,  and  atro- 
phy of  the  pancreas.  Pusinelli  (Ber- 
liner klin.  Woch.,  No.  33,  '90). 

Bronzed  diabetes  is  the  result,  and  not 
the  cause,  of  the  accompanying  hepatic 
cirrhosis,  which  is  thought  to  be  due  to 
augmented    function    of    the    liver-cells. 
Gilbert,  Castaigne,  and  Lereboullet  (Gaz. 
Hebdom.  de  MC-d.  et  de  Chir.,  May   17, 
1900). 
Pathogenesis. — It  wouM  appear,  from 
what  has  already  been  stated,  that  the 
causes  of  diabetes  are  miiltiplc;  it  is  evi- 
dent that  nervous  diabetes  dilTers  from 
pancreatic  diabetes.     In  obese  diabetic 
subjects  there  is  usually  no  appreciable 
lesion  of  the  pancreas,  and  certainly  no 
primary   lesion.      On   the  other  hand, 
there  are  no  nervous  elements  in  these 
cases.     This  is,  again,  a  dilTercnt  type 
of  diabetes,  and   it  would   be  easy  to 


multiply  the  number.  As  for  the  im- 
mediate cause  of  diabetes,  it  is  generally 
complex,  consisting  most  frequently  in 
an  increased  production  of  sugar  and  a 
diminution  of  glycolysis.  In  the  light 
of  our  present  knowledge  it  would  be 
difficult  to  say  much  more  upon  this 
point  if  one  ■\\'ishes  to  refrain  from  mere 
hypotheses. 

The  pancreas  is  always  the  cause  of 
glycosuria.  Case  of  diabetes  mellitus  in 
an  infant  of  six  months,  ascribed  to  the 
reflex  effect  of  teething  upon  the  pan- 
creas. Calcium  lactophosphate,  by  as- 
sisting the  evolution  of  the  teeth,  cured 
the  glycosuria.  Baumel  (Archives  de 
M6d.  des  Enfants,  Mar.,  1901). 

Autopsy  of  a  diabetic  negress  aged 
54  years.  The  pancreas  weighed  SO 
grammes,  was  soft  and  of  a  gray-yellow 
color.  Almost  every  island  of  Langer- 
hans  showed  microscopically  a  homo- 
geneous material  that  stained  -(vith 
eosin.  This  substance  at  times  lay  in 
the  midst  of  groups  of  cells,  but  was 
usually  in  contact  with  the  walls  of 
the  capillaries  penetrating  the  island,  or 
next  the  peripheral  fibrous  tissue,  and 
was  therefore  usually  between  the  re- 
maining cells  and  the  capillary  walls. 
The  cells  of  the  island  were  in  largo  part 
replaced,  so  that  between  the  hyaline 
particles  only  an  occasional  compressed 
fusiform  or  irregular  nucleus  co\ild  be 
seen.  The  hyaline  metamorphosis  was 
strictlj'  limited  to  the  islands  of  Langer- 
hans,  the  glandular  acini  remaining  in- 
tact. In  this  pancreas,  therefore,  a  le- 
sion of  obscure  etiology  had  destroyed 
the  islands  of  Langerhans,  while  those 
of  the  secreting  acini,  as  well  as  those 
of  other  organs,  were  unaffected.  The 
association  of  diabetes  mellitus  affords 
convincing  proof  that  the  islands  of 
Langerhans  are  intimately  connected 
with  the  glycogenic  metabolism.  E.  L. 
Opie  (Jour.  Exper.  Med.,  Mar.  25,  1901). 

Duration. — There  is  so  little  resem- 
blance between  the  various  cases  that  an 
average  duration,  even  supposing  that  it 
could  bo  rigorously  established,  would 
be  of  no  ini|)nrtance.     It  suffices  to  say 


DIABETES  MELLITUS.    TERmNATION.    PROGNOSIS. 


459 


that  in  a  general  way  the  average  dura- 
tion of  diabetes  is  several  years. 

I  am  consequently  much  surprised  at 
the  results  given  by  Griesinger  concern- 
ing 100  cases.  In  13  the  disease  only 
lasted  from  6  months  to  1  year;  in  39, 
1  to  2  years;  and  in  20,  2  to  3  years, 
which  would  make  the  duration  of  the 
disease  in  three-fourths  of  the  cases  from 
6  months  to  3  years. 

In  order  to  explain  such  remarkable 
figures  it  must  be  supposed  that  the  dia- 
betes was  latent,  in  the  beginning,  in  a 
large  number  of  the  patients,  and  that 
these  statistics  include  a  great  many  seri- 
ous cases. 

The  duration  in  children  varies  greatly. 
Out  of  34  cases  the  shortest  duration  was 
two  days;  the  longest  had  not  termi- 
nated at  the  end  of  five  years.  In  7  cases 
it  did  not  last  one  month,  and  of  these  1 
was  cured.  Seventeen  lasted  less  than  a 
year,  and  of  these  7  were  cured.  Ten 
lasted  over  a  year,  and  not  one  of  these 
recovered,  and  it  may  be  said  that  re- 
covery scarcely  occurs  where  the  dura- 
tion is  more  than  one  year.  C.  Stern 
(Archiv  f.  Kinderh.,  B.  11,  H.  2,  '89). 

The  main  prognostic  features  are: 
Age,  power  of  assimilation  of  carbohy- 
drates, early  recognition  of  the  affec- 
tion, the  presence  of  intercurrent  and 
complicating  diseases,  condition  in  life, 
state  of  the  urine,  and  the  power  of  ab- 
sorption of  other  foodstuffs  than  carbo- 
hydrates. II.  S.  Starr  (Med.  Record, 
Apr.  G,  1901). 

Termination. — It  is  evident  that  dia- 
betes, which  is  but  seldom  cured,  gener- 
ally ends  in  death.  In  explanation  of 
this  rather  naive  statement,  which  might 
lead  to  a  false  interpretation,  it  must  be 
borne  in  mind  that  the  duration  of  the 
disease  is  a  long  one,  and  that  in  a  great 
number  of  cases  mild  diabetes  allows  the 
patient  to  live  to  an  advanced  age. 

In  referring  to  the  complications  of 
the  disease,  I  have  already  mentioned  the 
frequency   of   phthisis,    and    the    even 


greater  prevalence  of  coma,  in  diabetics 
enjoying  a  certain  affluence.  To  these 
should  be  added  gangrene,  pneumonia, 
and  the  numerous  complications  which 
may  affect  the  organism  when  already 
debilitated  by  diabetes. 

In  a  certain  number  of  cases,  particu- 
larly in  arthritic  subjects,  the  diabetes 
may  be  changed  into  another  malady. 
Following  traumatisms,  it  may  end  (after 
a  certain  duration  of  the  glycosuria)  in 
simple  polytiria. 

Principal  reasons  why  diabetes  inter- 
feres with  operative  success:  1.  The 
sugar  circulation  in  tlie  blood  is  hygro- 
scopic, and  it  draws  water  from  all  the 
tissues  of  the  body  until  the  tissues  are 
actually  too  dry.  This  must  interfere 
with  the  normal  process  of  repair,  and 
it  probably  does  so  in  several  different 
ways.  2.  The  surgeon  must  give  these 
cases  special  attention,  because  the 
fluids  of  a  wound  loaded  with  sugar  are, 
in  all  probability,  excellent  culture- 
media  and  particularly  susceptible  to 
the  attacks  of  bacteria.  Rigid  asepsis 
is,  therefore,  demanded.  3.  Certain 
aUEesthetics  may  precipitate  an  im- 
pending nephritis  because  of  the  un- 
usual labor  involved  in  excreting  sugar. 
In  these  cases  nitrous  oxide  and  oxygen 
used  instead  of  the  other  antesthetics, 
especially  avoiding  the  use  of  ether.  R. 
T.  Morris   (Med.  News,  June  29,  1901). 

Prognosis.— It  may  be  inferred  from 
the  preceding  statements  that  it  is  diffi- 
cult to  speak  of  the  prognosis  of  diabetes 
in  general;  this  can  only  be  established 
in  each  individual  case. 

It  may  be  said,  however,  that  arthritic 
diabetes  and  many  cases  of  nervous  dia- 
betes are  usually  not  very  severe. 

In  (he  nervous  variety  the  glycosuria 
is  often  quite  moderate,  and  may  even 
disappear,  leaving  behind  a  simple  poly- 
uria. The  type  developed  under  the  in- 
fluence of  gout  in  arthritic  subjects  is 
associated  with  an  intermittent,  but 
abundant,  glycosuria,  and  is  compara- 
tively benign.  Certain  diseases  of  the 
pancreas,  such  as  calculi  of  Wirsung's 


460 


DIABETES  MELLITUS.     TREATMEiS^T. 


canal,  and  sclerosis  of  the  whole  paren- 
chyma, may  be  followed  by  a  rapid  and 
dangerous  diabetes.  There  are  other 
varieties  difficult  to  classify.  Lfipine 
(Sem.  M^d.,  Aug.  27,  '97). 

Deductions  based  on  twenty-two  origi- 
nal observations  as  well  as  the  literature 
of  the  subject  in  respect  to  the  influence 
of  diabetes  upon  the  functions  of  the 
female  organs  of  reproduction.  In  dia- 
betes mellitus  menstruation  is  generally 
diminished,  but  not  always  to  a  degi-ee 
parallel  to  the  sugar  in  the  urine.  Preg- 
nancy in  GG  per  cent,  is  undisturbed,  in 
the  remainder  is  prematurely  inter- 
rupted, but  more  often  by  miscarriage 
(seven  or  eight  months)  than  by  abor- 
tion. The  prognosis  for  the  mother  is 
likewise  doubtful.  Pruritus  vulvae,  boils, 
and  acuminate  condylomata  are  well- 
known  diabetic  symptoms.  Affections  of 
the  vaginal  mucous  membrane  and  uter- 
ine, and  necrosis  of  the  ovaries  are  not 
so  common.  Kleinwachter  (Zeitschrift  f. 
G.  u.  G.,  xxxviii,  H.  2,  '98). 

A  relative  cure  (urine  free  from  sugar 
on  a  diet  containing  200  grammes  of  car- 
bohydrate a  day)  is  to  be  anticipated 
if  at  the  onset  of  the  disease  80  to  85 
per  cent,  of  the  carbohydrate  consumed 
is  completely  burned  up  in  the  body.  F. 
Hirschfeld  (Berliner  klin.  Woeh.,  June 
18  and  25,  1900). 

The  progress  of  a  not  essentially  grave 
case  varies  considerably  according  to  the 
treatment  to  which  it  is  subjected.  It 
will  be  much  more  benign  if  the  patient 
is  intelligent  and  docile,  for  there  are 
few  chronic  diseases  in  which  proper  care 
and  attention  are  as  beneficial  as  in  dia- 
betes. 

During  the  period  from  1889  to  1899, 
inclusive,  the  total  number  of  deaths 
from  diabetes  in  New  York  City  was 
1867.  H.  Stein  (Jour.  Amer.  Med. 
Assoc,  Jan.  20,  1901). 

Treatment. — In  my  opinion,  the  treat- 
ment of  diabetes  should  not  be  a  system- 
atic one.  The  first  thing  to  be  done, 
and  this  is  a  precept  to  be  applied  in  the 
treatment  of  any  disease,  is  to  make  a 
careful  study  of  the  patient — to  indi- 


vidualize him,  as  it  were — to  watch  at- 
tentively the  effects  of  the  treatment,  and 
to  have  no  hesitation  in  modifying  the 
same  according  to  the  results.  The  diet 
is  more  important  than  the  medicinal 
treatment.  As  in  all  diabetics  the  power 
of  assimulating  sugar  is  more  or  less 
diminished,  it  is  important  to  limit  the 
ingestion  of  hydrocarbon  food.  The 
rule  is  to  forbid  it  as  far  as  possible,  and 
to  advise  a  diet  of  meat,  fish,  eggs,  green 
vegetables,  particularly  those  which  con- 
tain but  little  starch,  also  salad,  cheese, 
nuts,  etc. 

Too  great  a  quantity  of  meat  should 
be  avoided. 

In  healthy  persons  submitted  to  diet 
from  which  carbohydrates  are  absolutely 
excluded,  quantity  of  acetone  increases 
progressively  for  seven  or  eight  days, 
then  becomes  stationary  at  from  ^/j  to 
Vj  grain.  Diabetes  complicated  by  ace- 
tonuria  is  rather  rapid  in  its  evolution 
and  terminates  in  death  from  twelve  to 
twenty  months  in  cases  in  which  there 
is  no  gangrene.  Treatment:  hyperali- 
mentation (carbohydrates  in  small  quan- 
tities, albuminoids  in  not  too  great 
abundance,  fat,  and  alcohol);  rest. 
Hirschfeld  (Zeit.  f.  klin.  Med.,  B.  28,  H. 
I,  2,  '95). 

Some  patients  will  not  thrive  on  any 
diabetic  treatment.  Old  people  often 
emaciate  if  carbohydrates  are  dropped. 
In  the  diabetes  of  young  people  carbo- 
hydrates must  be  withheld  as  much  as 
possible.  Under  a  proteid  diet  young 
patients  live  longer.  Patients  generally 
improve  on  milk.  Jacobi  (Boston  Med. 
and  Surg.  Jour.,  Sept.  9,  '97). 

The  exclusion  of  carbohydrates  can 
never  be  complete  and  many  patients  do 
better  on  a  diet  not  too  rigid.  The  pa- 
tient should  be  put  on  a  rigid  proteid 
diet  to  see  what  can  be  aocoinpliBhed. 
Then  one  article  after  another  contain- 
ing more  or  leas  starch  or  sugar  may  bo 
added,  watching  the  urine,  and  finally 
the  diet  may  be  made  as  liberal  as  the 
individual  case  will  permit.  Tyson 
(Boston  Med.  and  Surg.  Jour.,  Sept.  9, 
'07). 


DIABETES  MELLITUS.    TREATMENT. 


461 


It  is  of  great  importance  to  prescribe 
definite  quantities,  and  to  test  the  effect 
of  tlie  diet  by  weekly  body-weighing, 
urine-measurement,  and  sugar-estima- 
tion. Carbohydrates  should  be  excluded 
as  rigidly  as  possible  without  damage  to 
the  nutrition  and  general  condition  of 
the  patient,  the  case  being  very  carefully 
watched.  Robert  Saundby  (Boston  Med. 
and  Surg.  Jour.,  Sept.  9,  '97). 

A  diabetic  should  be  placed  under  no 
different  conditions  of  diet  than  are 
granted  to  the  healthy  person.  Con- 
clusions:— 

1.  Sugar  is  always  present  in  the 
blood. 

2.  The  absence  of  carbohydrates  from 
the  diet  does  not  cause  a  disappearance 
of  the  blood-sugar. 

3.  The  systemic  and  ingested  albumin 
is  capable  of  furnishing  sugar  by  its 
decomposition. 

4.  An  increased  decomposition  of 
albumin  due  to  the  enforcement  of  a 
purely-nitrogenous  diet  means  an  in- 
creased metabolism  and  consequent  loss 
of  body- weight. 

5.  The  administration  of  carbohy- 
drates retards  metabolism. 

6.  The  diabetic  has  an  especial  pre- 
disposition toward  increased  metabolism. 

7.  The  diabetic  has  not  lost  the  power 
of  o.xidizing  sugar. 

8.  The  abnormal  metabolism  of  albu- 
min results  in  the  production  of  toxic 
bodies. 

9.  The  depressed  nervous  condition  of 
the  diabetic  is  especially  favorable  for 
the  action  of  these  bodies. 

10.  The  production  of  toxic  bodies  is 
prevented  or  retarded  by  the  administra- 
tion of  carbohydrates. 

The  diabetic  should  live  upon  a  diet 
which  keeps  his  body-metabolism  at  its 
lowest,  and  for  this  carbohydrates  are' 
necessary.  There  is  no  cure  for  the  con- 
dition; the  treatment  must  simply  be 
directed  to  prolong  life,  and  this  a  rigid 
protcid  diet  is  not  capable  of  doing. 
Munson  (Jour.  Amer.  Med.  Assoc,  May 
15,  '97). 

An  absolute  diet  without  vegetables 
should  not  be  given,  as  in  bad  cases  it 
leads  surely  to  more  rapid  accumulation 
of  acids  in  the  blood,  and  diabetic  coma 


is  an  acid  intoxication.  Even  in  the 
lightest  cases,  however,  for  two  or  three 
weeks  three  or  four  times  a  year  abso- 
lutely no  carbohydrates  should  be  taken, 
as  thus  the  metabolic  faculty  for  sugar 
which  has  been  injured  is  given  that 
strictly-physiological  rest  so  conducive 
to  its  recuperation.  Lee  (Med.  Record, 
May  7,  '98). 

In  diabetes  the  effort  now  is  to  so 
spare  the  faculty  for  the  absorption  of 
sugar  as  to  lead  to  its  recuperation,  and 
yet  not  to  precipitate  a  fatal  termination 
by  feeding  exclusively  on  albumins  and 
so  leading  to  increased  acidity  of  the 
blood.  For  this  the  sugar-metabolic 
limits  of  the  organism  having  been 
found  by  a  series  of  urinary  examina- 
tions, these  are  never  overstepped,  a 
greater  quantity  of  carbohydrates  are 
never  allowed  than  can  be  consumed, 
and  then  three  or  four  times  a  year,  for 
a  period  of  two  or  three  weeks,  the  pa- 
tient is  put  upon  an  absolute  diet,  with 
all  carbohydrates  excluded.  Leo  (Phila. 
Med.  Jour.,  Mar.  17,  '98). 

The  proper  dieting  is  of  the  greatest 
importance  in  the  treatment  of  diabetes. 
Drugs  have  practically  no  influence  on 
the  process.  The  benefit  derived  from 
a  stay  at  some  watering-place  is  ascribed 
to  the  diet,  which  consists  exclusively 
of  fat  and  proteid.  In  saccharin  we  pos- 
sess an  excellent  substitute  for  sugar, 
and  one  which  can  be  taken  for  years 
with  impunity.  Notwithstanding  the 
many  preparations  on  the  market,  the 
proper  substitutes  for  bread  have  not 
yet  been  found,  for  those  which  have 
been  tried  either  become  disagreeable  to 
the  taste  after  awhile  or  they  are  too 
rich  in  carbohydrates.  If  the  condition 
permits  the  use  of  any  bread  at  all, 
Graham  bread  is  to  be  preferred.  One 
should  never  forget  that  the  diabetic 
needs  more  actual  food  than  the  well, 
since  he  loses  so  much,  and  underfeeding 
should  be  avoided.  As  with  morphine, 
it  is  generally  better  and  more  agreeable 
for  the  patient  to  \>-ithdraw  the  forbid- 
den articles  of  food  slowly  than  rapidly. 
The  scales  should  be  used  freely  to 
watch  the  body-weight.  If  the  urine 
has  been  free  from  sugar  for  several 
weeks  small  quantities,  say,  25  grammes 


46S 


DIABETES  JklELLITUS.    TREATJIENT. 


(6V«  drachms),  of  bread  daily  are  per- 
mitted, and  the  amount  is  increased 
daily  10  grammes  (2Va  drachms)  till 
70  to  100  are  reached,  which  is  suffi- 
cient for  most.  As  soon  as  traces  of 
sugar  again  appear  the  bread  must  be 
reduced  in  some  and  in  others  entirely 
withdrawn.  H.  Eichhorst  (Therap. 
Monats.,  Sept.,  1902). 

The  abiise  of  the  albuminoids  by  dia- 
betic patients  may  cause  not  only  the 
usual  disturbances,  but  it  may  also  in- 
crease the  sugar  in  the  urine,  as  Naunyn 
has  justly  remarked.  It  has  also  been 
noticed  that  an  exclusively-meat  diet 
may  bring  about  some  particular  dys- 
crasia,  ending  in  diabetic  coma.  This 
exclusive  diet,  which  was  formerly  lauded 
by  Cantani,  is  consequently  not  to  be 
recommended.  It  is  very  difficult  to  ab- 
solutely deprive  the  patient  of  bread,  so 
a  small  quantity,  as  small  as  possible, 
may  be  allowed,  or,  in  place  of  this,  an 
equally-small  portion  of  potatoes. 

Levulose  can  be  given  in  moderate 
quantities  in  slight  forms  of  diabetes, 
without  injurious  results  as  regards 
sugar-excretion,  urine,  etc.  Utilized  in 
the  system,  though  dextrose  and  cane- 
sugar  excreted.  Grube  (Zeit.  f.  klin. 
Med.,  B.  20,  H.  3,  4,  '95). 

[Levulose  may  generally  be  given  in 
small  doses  to  patients  sufTering  from 
mild  diabetes;  but,  if  small  daily  dose 
be  e.xceeded,  excretion  of  sugar  increased 
without  benefit  to  patient.  R.  LiSpine, 
Assoc.  Ed.,  Annual,  '96.] 

In  eases  of  diabetes  the  addition  of  a 
small  quantity  of  alcohol  (1  to  2 '/« 
ounces  per  diem)  has  no  ill  effect.  In 
cases  where  there  is  already  cardiac 
weakness  or  vascular  disease,  alcohol 
should  be  u.scd  cautiously.  Beer  is  for- 
bidden, as  it  contains  the  most  extractive 
matters,  which  are  chiefly  carbohy- 
drates. All  sugar-containing  liqueurs 
and  Bweet  wines  are,  of  course,  forbid- 
rlcn.  Wine,  cognac,  certain  forms  of 
brandy,  etc.,  may  be  allowed.  Hirsch- 
fcld  (iierlincr  klin.  Woeli.,  Feb.  4,  '95). 
Eight  diabetic  patients  could  com- 
pletely oxidize  levulose  in  daily  amounts 


of  from  6  to  25  drachms.  Levulose  not 
only  does  not  increase,  but  rather  dimin- 
ishes, the  amount  of  nitrogenous  output, 
both  urine  and  fteces  being  examined. 
E.  de  Renzi  and  E.  Eeale  (Wiener  med. 
Woch.,  '97). 

There  are  carbohydrates  that  seem  to 
have  little  influence  on  glycosuria,  such 
as  levulose,  inulin,  and  mannite.  Cer- 
tainly the  rule  is  that  the  group  of 
sugars  which  deviate  polarized  light  to 
the  left  are  less  injurious  than  those 
tliat  deviate  it  to  the  right.  Bouchard 
(Sem.  Mod.,  Mar.  26,  '97). 

Flour  made  from  edible  pine-nuts 
recommended  for  diabetics.  It  is  fine, 
slightly  yellow,  bland  in  taste,  contains 
no  starch,  and  7  per  cent,  of  cane-sugar. 
If  raised  with  yeast,  sugar  is  decomposed 
so  that  only  a  fraction  of  1  per  cent,  can 
be  found.  Bread  and  cake  made  from  it 
are  relished,  and  it  is  an  agreeable  sub- 
stitute for  wheat-bread.  The  flour  is 
known  as  the  "Chicago  Sanitary  Flour." 
N.  S.  Davis,  Jr.  (Jour.  Araer.  Med. 
Assoc,  Nov.  5,  '98). 

Strict  milk  diet  in  diabetes  combined 
with  hydrotherapeutics,  systematic  exer- 
cises, fresh  air,  and  sunshine  advocated. 
Winternitz  and  Strasser  (Centralb.  f. 
inncre  Med.,  Nov.  11,  '99). 

Diabetics  must  be  taught  to  use  fats 
in  abundance.  They  are  the  only  sub- 
stances that  can  succeed  in  stilling  the 
craving  for  the  starches  and  sugars  and 
can  properly  replace  them.  Editorial 
(Med.  News,  Feb.  17,  1900). 

Thirty-four  difl'ercnt  kinds  of  potatoes 
subjected  to  examination,  the  most  nota- 
ble result  of  the  proceeding  being  that 
the  potatoes  employed  for  diabetic  feed- 
ing should  be  fresh  and  mature,  and  that 
the  central  portion  of  the  tuber,  being 
the  most  watery,  the  richest  in  nitroge- 
nous matters,  and  the  poorest  in  starchy 
ingredients,   is  the  best  suited   for   the 
purpose.       A.     Mosse     (Klinisch-tlierap. 
Woch.,  Oct.  7,  1900). 
Ebstein  has  recently  very  highly  rec- 
ommended aleuronat  bread,  which  con- 
tains a  much  greater  proportion  of  vege- 
table albumin  than  any  other  thus  far 
recommended  for  diabetics,  and  which 
may   consequently   be   taken    in   larger 


DIABETES  IIELLITUS.    TREATMENT. 


463 


quantities.  With  regard  to  drinks,  the 
abuse  of  beer,  alcohol,  and  wine  should 
be  forbidden. 

The  above  are  the  main  features  in 
the  diet;  it  is  necessary  to  conform  to 
them  as  far  as  possible,  at  the  same  time 
avoiding  all  exaggerations. 

Sugar-free  milk  contains  approxi- 
mately 3  per  cent,  of  proteid  and  5  per 
cent,  of  fat.  If  3  pints  are  talcen  in  a 
day,  the  food-value  amounts  to  990 
calories,  or  nearly  one-third  of  the  total 
amount  required,  while  the  amount  of 
fat  -which  the  patient  obtains  is  equiva- 
lent to  fully  3  ounces  of  butter.  In 
cases  in  which  a  small  amount  of  carbo- 
hydrate is  desirable,  it  is  sometimes  best 
to  substitute  sugar-free  milk,  and  give 
carbohydrates  in  the  form  of  potatoes 
or  bread,  as  this  enables  the  patient  to 
ingest  a  larger  amount  of  fat.  Robert 
Hutchison  (Lancet,  June  22,  1901). 

In  the  severe  forms  of  diabetes,  the 
diet  must  naturally  be  much  more  lim- 
ited, except  in  cases  where  coma  appears 
imminent.  The  marked  reaction  of  the 
urine  with  the  perchloride  of  iron,  and 
especially  the  diminution  of  the  appe- 
tite, are  the  chief  premonitory  symptoms 
of  this  danger.  In  such  cases  every  one 
is  agreed  that  it  is  well  to  abolish  the 
restricted  diet. 

Opium  is  of  temporary  service,  at  least, 
but  I  have  never  found  it  beneficial  for 
any  length  of  time.  It  causes  a  reduc- 
tion in  the  quantity  of  sugar.  Villemin 
advised  the  addition  of  belladonna.  I 
have  never  been  able  to  convince  myself 
of  the  advantage  of  its  use,  and  have 
found  it  to  cause  dryness  of  the  throat. 
Antipyrine  is  sometimes  most  useful;  it 
frequently  diminishes  excessive  polyuria 
and  reduces  the  sugar. 

The  value  of  antipyrine  in  three  cases 
of  long  standing  (one  of  twenty  years') 
verified.  The  results  were  immediate, 
and  all  traces  of  the  condition  promptly 
disappeared — in  one  case  permanently, 
in  another  for  a  long  time  after  a  with- 


drawal of  the  remedy;  in  the  third  case 
the  quantity  of  urine  at  once  rose  to  its 
former  amount  upon  the  withdrawal  of 
antipyrine,  but  upon  readministration 
fell  again.  Beginning  the  treatment,  the 
medicament  should  be  given  to  the 
amount  of  31  grains,  per  diem,  this 
amount  increased  by  15  V,  grains  daily 
until  1  'A  drachms  are  reached  or  the 
amount  of  urine  diminished;  and  after 
eight  days  should  be  omitted  in  order  to 
see  if  the  results  are  permanent.  Opitz 
(Deut.  med.-Zeit.,  Aug.  8,  '89). 

Antipyrine  tried  with  the  object  of  di- 
minishing the  amount  of  sugar,  uric  acid, 
and  urea,  but  the  diminution  only  fleet- 
ing. Beer-yeast  of  no  use.  Pancreas  in 
the  fresh  state  in  daily  doses  of  30 
grammes  given  with  no  better  success. 
The  corner-stone  of  treatment  in  dia- 
betes is  diet.  Mousse  (La  Sem.  JIf'd., 
Aug.  19,  '96). 

Antipyrine  is  not  always  indicated, 
however.  It  is  only  used  in  certain  cases 
of  diabetes,  probably  those  in  which  the 
hyperproduction  of  sugar  is  very  great, 
for  my  researches  have  sho\\Ti  that  it 
tends  rather  to  counteract  the  destruc- 
tion of  the  sugar;  moreover,  the  use  of 
antipyrine  cannot  be  long  continued. 
Salicylate  of  soda  has  also  been  of  serv- 
ice; its  action  is  similar  to  that  of  anti- 
p}Tine,  with  the  exception  that  it  does 
not  equally  diminish  the  polyuria.  Qui- 
nine acts  in  the  same  way  as  the  anti- 
pyrine and  the  salicylate  of  soda,  and 
has  the  advantage  of  being  tonic. 

Sodium  salicylate,  as  recommended  by 
Ebstein,  used  in  twenty  patients.  Diet 
and  regimen  being  the  same,  it  seemed 
in  large  doses — 75  to  SO  grains  daily — to 
have  a  marked  eflfect  in  diminishing  the 
amount  of  sugar  in  the  urine.  Stopping 
of  the  drug  would  cause  the  sugar  to  re- 
appear, to  disappear  on  resuming  the 
medication.  R.  T.  Williamson  (Brit. 
Med.  Jour.,  Mar.  30,  1901). 

Ebstein's  plan  of  treating  diabetes  by 
large  doses  of  salol  tried  in  nine  cases. 
Three  severe  cases  showed  no  improve- 
ment, but  the  other  six,  moderately  se- 


464 


DIABETES  MELLITUS.    TREATMENT. 


vere  cases,  were  markedly  benefited.  Id 
the  latter,  strict  diet  ca\ised  the  sugar 
to  disappear;  but  the  improvement  was 
very  gradual.  Salol,  on  the  other  hand, 
caused  the  sugar  to  fall  at  once.  Al- 
though the  drug  was  administered  in  15- 
grain  doses,  four  times  a  day,  for  five 
days,  no  case  showed  gastric  disturb- 
ances or  tinnitus.  The  action  does  not 
seem  to  last  long,  as  the  sugar  gradu- 
ally reappeared  after  the  drug  was 
stopped.  Tesehemacher  (Therap.  Mon- 
ats.,  Jan.,  1901). 

Jambul  is  also  recommended;   but  in 
many  cases  it  fails  completely.    Its  mode 
of  action  requires  to  be  further  studied. 
In  the  treatment  of  glycosuria,  using 
the  rind  instead  of  the  fruit  in  the  prep- 
aration of  the  extract  of  jambul  makes 
it    more   agreeable   in   taste    and    much 
cheaper   than    the   fruit.     As    much    as 
1 '/,  ounces  per  day  can  be  administered 
for  a  long  period  without  disagreeable 
effects.     It   is   best   given   in   water   or 
wine.    Vix  (Ther.  Monats.,  Apr.,  '93). 

Eugenia  jambolana  is  almost  a  specific 
in  diabetes,  best  given  in  syrup  or  juice 
of  ripe  fruit  mixed  with  water  to  form 
a  sherbet.  The  powdered  seeds  or  a 
fluid  extract  of  the  seeds  is  an  exceed- 
ingly valuable  form  in  which  to  exhibit 
it.    Rudolf  (Bull,  of  Pharm.,  Jan.,  '98). 

For  a  number  of  years,  particularly  in 
fatty  diabetes,  I  have  been  using  perman- 
ganate of  potassium:  an  agent  which  in- 
creases the  oxidation.  I  use  a  5-per-cent. 
solution,  the  patient  taking  2  or  3  tea- 
spoonfuls,  or  even  more,  per  day. 

Fourteen  patients  treated  with  forms 
of  calcium,  generally  as  phosphate  and 
carbonate.  This  treatment  has  appar- 
ently no  efTect  upon  tlie  excretion  of 
sugar,  but  the  patient  feels  better  and 
increases  in  weight.  Of  these  patients 
three  were  young  subjects  who  were 
markedly  benefited.  Upon  the  others 
there  was  no  result.  The  treatment, 
however,  produced  no  detriment.  Karl 
Grube  (Ther.  Monats.,  II.  5,  S.  258,  '9C). 

The  efTccts  of  uranium  nitrate  are  (1) 
to  diminish  the  thirst,  (2)  to  reduce  the 
amount  of  urine  passed,  and  (3)   to  re- 


duce the  percentage  of  sugar.  Like  all 
the  other  drugs  used  in  the  treatment 
of  diabetes,  uranium  nitrate  does  not  in- 
fluence all  cases  alike  favorably.  Samuel 
West  (Ther.  Gaz.,  Sept.,  '97). 

Hepatic  extract,  prepared  as  follows, 
should  be  given  daily  per  rectum :  3 '/, 
to  5  Vi  ounces  of  fresh  pigs'  liver  are 
minced  in  a  machine  and  macerated  for 
2  hours  in  7  to  9  ounces  of  water  at 
95°  to  100°  F.,  then  filtered  through 
muslin  and  expressed.  This  amount  is 
usually  well  borne  as  an  enema;  if  it 
is  not,  divided  doses  nmst  be  given. 
The  cases  of  diabetes  which  derive  the 
most  benefit  from  the  treatment  are 
those  of  definite  hepatic  origin.  If  the 
hepatic  cell  is  too  diseased,  the  treat- 
ment fails.  Summing  up  12  cases,  3 
were  benefited  temporarily,  5  were  im- 
proved permanently,  and  in  4  the  gly- 
cosuria ceased  completely.  It  is  inter- 
esting to  note  that  in  most  cases  urea 
and  uric  acid  are  increased  while  liver 
is  taken. 

One  deduction  is  certain:  that  the 
extract  lessens  the  excretion  of  glucose; 
whether  by  increasing  the  power  of 
storing  up  reserves  of  sugar,  or  by  caus- 
ing a  more  rapid  destruction  of  ingested 
hydrocarbons,  remains  uncertain.  The 
antitoxic  function  of  the  liver  is  little,  if 
at  all, — the  biliary  but  slightly, — while 
the  glycogenic  and  uropoictio  functions 
are  markedly  increased.  Gilbert  and 
Carnot  (La  Sem.  Med.,  May  10,  '97). 

1.  In  diabetes  mellitus  there  is  a  dis- 
tinct loss  of  phosphorus,  lime,  and  chlo- 
rine by  every  form  of  diet. 

2.  Addition  to  diet  of  phosphate  of 
lime  induces  a  slight  saving  of  nitrogen; 
addition  of  salt  docs  not  do  this. 

3.  Addition  of  fatty  matter  produces 
the  same  elfcot  as  phosphate  of  lime. 

4.  Addition  of  phosphate  of  lime  to 
the  diet  causes  diminished  excretion  of 
sugar.  W.  v.  Moraczewski  (Zcit.  f.  klin. 
Med.,  B.  xxxiv,  II.  1,  2,  '08). 

In  diabetes,  Fowler's  solution  and  co- 
deine give  best  rosultH,  together  with 
tonics,  such  as  muriatic  acid,  strych- 
nine, and  quinine,  as  indicated.  H.  G. 
Norton   (Med.  News,  July  9,  '98). 

Arsenous  acid  in  doses  as  large  as  '/• 
grain   a  day   recommended  in  diabetes. 


DIABETES  MELLITUS.    TREATMENT. 


465 


In  cases  of  progressive  emaciation  a 
mixture  of  100  grammes  of  glycerin  and 
2  grammes  of  tartaric  acid  with  some 
rum,  added  to  a  quart  of  water,  is  verj 
useful.  Jaecoud  (MC-d.  Mod.,  No.  14, 
■98). 

Methylene-blue  used  in  two  cases  of 
diabetes  mellitus,  in  average  doses  of  5 
grains  daily.  In  one  case,  after  treat- 
ment for  five  weeks,  subjective  symp- 
toms were  relieved,  and  glucose  reduced 
to  mere  trace.  In  second  case,  in  which 
urine  contained  about  one  ounce  of  sugar 
per  quart,  the  saccharin  content  was  re- 
duced to  1 V.  drachms  per  quart  after 
treatment  for  four  weeks.  Estay  (Bull. 
GOn.  de  ThOr.,  No.  2,  '98). 

Where  aperients  fail  in  diabetes,  co- 
caine in  small  doses  (Va-grain  doses  twice 
or  thrice  daily)  will  not  only  brace  up 
the  muscular  system  generally  and  re- 
move the  sense  of  fatigue  so  frequently 
present  in  these  patients,  but  overcomes 
constipation.  Thomas  Oliver  (Lancet, 
Aug.  13,  '98). 

Eulexine  used  with  gi'eat  satisfaction 
in  diabetes.  E.  C.  Skinner  (Louisville 
Med.  Monthly,  Oct.,  '98). 

Diabetes  believed  to  be  due  to  pto- 
maine poisoning  or  to  bacterial  invasion 
of  the  organism.  Therefore  mercuric 
chloride  has  been  used  in  beginning  doses 
of  Vi:  grain  three  times  daily,  increasing 
within  a  week  to  ^/o  grain.  Three  weeks 
of  this  treatment  are  sufficient  to  cause 
a  marked  reduction  in  the  amount  of 
svigar  and  improvement  in  the  general 
health.  After  this  time  the  dose  is  de- 
creased to  '/,  grain  in  the  day.  Abraham 
Mayer  (Med.  Record,  Dec.  10,  '98). 

Cases  in  wliich  the  administration  of 
liver-subslnnce  brings  about  improve- 
ment are  those  in  which  the  diabetes  is 
connected  with  a  functional  inadequacy 
of  the  liver  (characterized  by  diminution 
of  urea,  urobilinuria,  etc.).  On  the  other 
hand,  cases  of  diabetes  that  are  not  bene- 
fited or  are  even  made  worse  by  the 
treatment  are  those  in  which  the  glyco- 
suria appears  to  depend  on  overactivity 
of  the  organ.  Gilbert  (Inter.  Congress 
of  Med.;    Brit.  Med.  Jour.,  Oct.  13,  1900). 

Opium,  arsenic,  and  bichloride  of  mer- 
cury are  the  drugs  of  most  service. 
Opium,  which  is  of  the  greatest  general 


use  in  controlling  various  annoying 
symptoms,  should  not  be  used  continu- 
ally, but  interruptedly.  It  should  be 
given  in  small  doses  (not  more  than  V, 
grain  three  times  a  day  at  first),  and 
its  constipating  effect  should  be  coun- 
teracted by  cascara  sagrada  or  other 
laxative.  There  are  certain  cases  of 
diabetes,  generally  occurring  in  middle 
age,  which  were  like  a  bacterial  invasion 
or  ptomaine  poisoning.  In  these  the 
bichloride  of  mercury  has  a  certain,  per- 
haps specific,  value.  The  dose,  at  first 
small,  should  be  increased  to  '/»  grain. 
Even  if  the  sugar  is  not  entirely  elimi- 
nated, many  patients  can  get  along  very 
comfortably  for  years.  The  diabetic's 
attention  should  be  diverted  as  much  as 
possible  from  himself,  and  he  should  be 
free  from  professional  or  business  cares 
and  other  sources  of  worriment.  He 
should  wear  warm  clothing  and  avoid 
fatigue  and  all  excesses.  Massage  and 
carbonic-acid  baths  are  often  of  great 
service,  and  visits  to  various  health  re- 
sorts, with  the  use  of  mineral  waters  to 
aid  digestion,  have  a  good  eflfect.  About 
2.5  per  cent,  of  diabetics  die  from 
phthisis.  Abraham  Mayer  (Boston 
Med.  and  Surg.  Jour.,  Apr.  18,  1901). 
Alkaline  waters  perceptibly  diminish 
the  sugar  in  the  urine.  Their  use  should 
consequently  not  be  restricted,  unless 
the  patient  be  very  much  debilitated. 
Vichy  water,  taken  at  the  springs,  is 
particularly  recommended  for  fatty  dia- 
betics. 

Carlsbad  water  also  appears  to  be  use- 
ful. 

For  diabetic  patients  who  are  already 
somewhat  cachectic,  Bourboule  water, 
which  contains  considerable  arsenic,  is 
preferable. 

If  the  kidnej-s  are  inactive,  Contrexe- 
ville  should  be  recommended. 

Independently  of  the  use  of  mineral 
waters,  it  is  better  not  to  neglect  baths. 
ITydrotherapy  may  be  advised  for  dia- 
betic patients  who  are  still  young  and,  as 
a  rule,  lotions  of  cold  salt  water  in  sum- 
mer, and  warm  baths  followed  by  friction 
30 


466 


DIABETES  ilELLITUS. 


DIGITALIS. 


in  winter.  At  Aix  warm  douches  and 
massage  are  resorted  to.  Generally  speak- 
ing, massage  is  always  useful  for  patients 
whose  weak  condition  does  not  allow  of 
prolonged  muscular  exercise.  Active 
movements,  if  they  do  not  fatigue  the 
patient,  are  preferable  to  the  passive 
movements.  Warm  climates  have  a  fa- 
vorable influence;  when  the  patients 
are  not  greatly  debilitated,  mountain-air 
has  also  been  recommended. 

Physicians  are  sometimes  consulted  as 
to  the  advisability  of  allowing  the  use  of 
saccharin  in  diabetes,  to  replace  the  taste 
of  sugar. 

I  have  not  seen  any  bad  effects  follow- 
ing the  use  of  saccharin  when  employed 
in  small  doses.  An  equal  quantity  of 
bicarbonate  of  soda  should  be  added. 

In  diabetic  coma  the  following  intrav- 
enous injection  should  be  used: — 

5  Chloride  of  sodium,  1  drachm. 
Bicarbonate      of     sodium,     2  V2 

drachms. 
Distilled  water,  1  quart. 

A  strict  milk  diet  should  be  instituted 
at  once,  and  the  elimination  of  poisons 
should  be  assisted  by  the  administration 
of  saline  purgatives.  Should  the  heart 
be  feeble  or  irregular,  full  doses  of  digi- 
talis and  ergotine  are  to  be  given. 

Results  of  obsci-vation  on  treatment 
of  diabetic  coma  by  subcutaneous  or  in- 
travenous injections  of  bicarbonate  and 
chloride  of  sodium.  1.  Alkaline  injec- 
tions have  given  incontestable  results 
in  diabetic  coma.  2.  These  injections 
are  best  intravenous,  the  subcutaneous 
method  being  too  slow.  3.  If  possible, 
intervention  should  precede  coma,  as  Lu- 
pine points  out.  When  the  patient 
shows  progressive  aggravation,  a  feeble 
pulse,  lowered  urine,  slow  respiration, 
witli  increasing  dyspna'a,  nausea,  and 
vomiting,  an  intravenous  alkaline  infu- 
sion of  from  .300  to  375  grains  of  bicar- 
bonate of  sodium  with  112 '/>  grains  of 
chloride  of  sodium  to  1000  parts  of  water 


is  indicated.     jM.  A.  Berson    (Jour,  dea 
Sci.  U6±  de  Lille,  Aug.  6,  '9S). 

Nineteen  eases  of  diabetic  coma  treated 
by  saline  injections,  mostly  published 
in  Germany  and  England,  collected;  of 
these  only  one,  a  case  of  LOpine's,  re- 
covered from  the  coma;  but  few  or  none 
appeared  to  have  received  such  copious 
injections.  Koget  and  Balvay  (Lyon 
JKd.,  Jan.  S  and  15,  "99). 

If  there  is  any  reason  to  fear  coma, 
an  energetic  use  of  alkalies  should  be 
prescribed.  In  these  circumstances  an 
hypodermic  injection  of  strychnine  must 
be  given,  and  '/=  ounce  of  soda  bi- 
carbonate should  be  administered  as  an 
enema  in  hot  water,  and  repeated  every 
hour  until  improvement  tflkes  place. 
Saundby  (Practitioner,  July,  1900). 

Good  results  follow  the  prophylactic 
administration  of  sodium  bicarbonate: 
15  to  30  grains  daily.  In  the  fully  de- 
veloped diabetic  coma  it  has  proved  a 
failure.  The  use  of  calcium  carbonate 
has  been  productive  of  good  results.  H. 
Stern  (Jour.  Amer.  Med.  Assoc,  Dec. 
8,  1900). 

R.  Lepine, 

I-yons. 

DIAKRHCEA.  See  Intestines,  Dis- 
orders OF. 

DIARRHCEA,  INFANTILE.  See  In- 
fantile DiARRiifEA  and  Cuolera  In- 
fantum. 

DIGITALIS.— Digitalis  is  indigenous 
to  Great  Britain,  Ireland,  and  many 
parts  of  Europe,  where  it  grows  wild  on 
gravelly  or  sandy  soils  in  young  planta- 
tions, at  hedge-sides,  and  in  hill-past- 
ures. It  has  been  introduced  into 
America,  but  is  more  grown  as  an  orna- 
ment to  gardens  and  in  hot-houses  than 
for  commercial  purposes,  and,  moreover, 
it  is  claimed  that  it  is  not  so  active 
medicinally  as  that  obtained  abroad. 
Digitalis  purpurea  is  the  ofTicial  plant, 
though  some  pharmacopreias  take  cog- 
nizance of  other  forms,  notal)ly  H.  Am- 


DIGITALIS.     PKEPAIiATIOXS  AND  DOSES. 


467 


higua,  Murr.,  ^vhich  was  extensively  ex- 
ploited by  Paschkis  a  few  years  ago;  and 
all  seem  to  possess  much  the  same  gen- 
eral activity,  though  purple  digitalis 
alone  has  been  at  all  carefully  studied. 
The  Digitalis  purpurea,  which  is  the 
source  of  all  our  medicinal  preparations, 
is  a  biennial  or  perennial  with  numerous 
drooping,  purple-spotted  (occasionally 
white)  or  purple  flowers,  an  erect  stem 
from  twelve  to  fifty  inches  high,  and 
large  alternate,  ovate,  lanceolate,  crenate, 
rugose  leaves  of  downy  character,  espe- 
cially on  their  pale-  or  light-  reddish- 
brown  under-surfaces,  and  tapering  into 
winged  roof-stalks.  The  leaves,  which 
constitute  the  official  digitalis,  should 
be  of  the  second  year's  growth — when 
they  are  much  more  oval,  and  also 
more  active  than  those  of  the  first 
year — and  gathered  either  in  July  or 
late  in  June,  before  the  small,  round, 
graj'-brown  seeds  begin  to  ripen,  and 
when  about  two-thirds  of  the  flowers 
have  expaudod ;  they  should  also  be 
dried  in  the  dark,  in  baskets,  over  a  mod- 
erately-heated stove  or  in  a  brick  oven, 
and  if  properly  cured  will  exhibit  a 
dark-green  hue  and  an  almost  total  lack 
of  odor,  except  that  which  generally  ac- 
crues to  dried  herbs  and  leaves  and  fre- 
quently is  described  as  "tea-like";  they 
have  a  decided  nauseous  and  bitter  taste. 
Much  of  the  uncertainty  that  accrues  to 
the  medicinal  use  of  digitalis  is  doubt- 
less due  to  improper  seasons  of  plucking, 
improper  drying  or  packing,  and  age; 
for  even  the  best  qualities  and  most  care- 
fully collected  and  husbanded,  even 
when  pressed  and  wrapped  in  stout 
paper,  or  kept  in  tins  that  are  not  her- 
metically scaled,  manifest  distinct  loss 
of  remedial  virtues  after  a  few  months, 
and  may  become  practically  inert  at  the 
expiration  of  a  year.  Digitalis-leaves, 
too,  as  found  in  open  market,  more  espe- 


cially the  cheaper  varieties,  are  probably 
not  of  D.  purpurea;  or  the  latter  may 
be  adulterated  with  leaves  of  the  com- 
mon potato,  the  black  nightshade  or 
black  mullein  {Solarium  tuberosum,  S. 
nigrum,  and  Verhuscum  nigrum)  or  all 
three,  or  Coniza  squamosa,  which,  in  a 
dry  state,  somewhat  resemble  those  of 
the  purple  fox-glove.  Such  sophistica- 
tion, however,  may  be  detected  by  boil- 
ing one  of  the  suspected  leaves  in  the 
smallest  possible  quantity  of  water,  pour- 
ing upon  an  opalescent  plate,  and  adding 
a  drop  of  ferric  chloride:  if  a  green  re- 
action occurs,  the  leaf  is  digitalis;  if 
blue,  it  is  not. 

Preparations  and  Doses.  —  Digitalis- 
leaves,  powdered,  ^/^  to  3  grains. 

Digitalis  abstract,  V2  to  1  grain 
(Squibb's,  2  to  5  grains). 

Digitalis  infusion  (B.  P.),  1  to  4 
drachms  (U.  S.  P.,  2  to  8  drachms). 

Digitalis  extract,  solid,  V«  to  Vj 
grain. 

Digitalis,  fluid  extract  and  nonnal 
liquid,  1  to  2  minims. 

Digitalis  tincture  (B.  P.),  5  to  40 
minims. 

Digitalis  tincture  (U.  S.  P.),  3  to  30 
minims. 

Digitalis,  ethereal  tincture,  2  to  8 
minims. 

Digitalis-vinegar  (G.  P.  digitalis,  1; 
alcohol,  1;  vinegar,  9  parts),  10  to  30 
minims. 

Digitalisin  (concentration),  '/,,  to  V« 
grain. 

Digitalein  (Schmiedeberg's),  '/,«  to 
V35  grain. 

Digitaleine   (Xativelle's).     See  Digi- 

TONIN. 

Digitalin  (U.  S.  P.  and  B.  P.),  ob- 
solete. 

Digitalin  (Homollis  &  Qucvenne's 
"French  Codex"),  V«o  to  V,,  grain. 


468 


DIGITALIS.    PKEPAEATIONS  AND  DOSES. 


Digitalin  (Schmiedeberg's,  or  digi- 
talin  verum,  Kiliani),  Vei  to  V32  grain- 

Digitaline  (Xativelle's),  V250  to  Vao 
grain. 

Digitonin  (  Xativelle's  digitaleine),  not 
employed. 

Digitoxin  (Schmiedebergs),  V250  to 
Vi:5  grain. 

Digitalis  Abstract. — This  is  merely 
a  dried  solid  extract  powdered  and  mixed 
with  some  material  to  prevent  its  sub- 
sequent firm  agglutination,  and  should 
be  made  without  heat  by  the  substitute 
process.  It  presents  a  green  color  and 
the  characteristic  digitalic  odor.  Within 
a  few  days  after  making  and  placing 
in  a  bottle,  the  powder  contracts  very 
much  and  adheres  in  a  fairly-solid  mass 
that  is,  however,  easily  broken  up  by 
means  of  a  stiff  spatula,  and  then  readily 
rubbed  to  powder  again.  The  abstracts 
in  market,  however,  vary  in  strength 
and  are  obsolescent. 

The  solid  extract  possesses  the  same 
odor,  somewhat  intensified,  as  the  ab- 
stract, and  properly  made  is  of  so  dark 
green  a  hue  when  seen  in  mass  as  to  be 
nearly  black;  but,  when  thinly  spread, 
the  green  is  very  marked  and  intense.  A 
brownish  solid  extract  is  suspicious  and 
suggestive  of  too  much  heat  employed  in 
manufacture,  in  which  case  it  is  apt  to 
prove  inert. 

Infusion. — The  infusion  requires  to 
be  made  with  great  caution  and  from 
carefully-selected  leaves  of  bright  color 
and  distinctive  odor,  also  without  undue 
heat.  That  of  the  U.  S.  P.  is  only  about 
half  the  strength  prescribed  by  the  B. 
P.:  a  fact  that  is  to  be  taken  into  ac- 
count according  to  the  residence  or 
locality  of  prescriber  or  patient.  Fresh 
leaves  are  nearly  one-third  more  active 
than  the  infusion. 

Whr>n  nn  infuBion  of  digitalis  is  given 
to   indivi'Iiinls  with   normal   eironlatory 


apparatus  in  quantities  equal  to  that  ad- 
ministered to  persons  with  valvular  dis- 
ease, there  is  no  increase  in  tlie  blood- 
pressure  nor  in  the  quantity  of  urine 
excreted,  while  the  reverse  is  true  of 
persons  who  have  heart  disease.  Ernst 
von  Czyhlarg  (Wiener  klin.  Rund.,  Apr. 
15,  1900). 

Fluid  Esteact. — A  good  tluid  ex- 
tract should  represent  a  definite  amount 
of  drug,  viz.:  one  gramme  of  leaves  to 
the  cubic  centimetre  of  fluid.  So  called 
"normal  liquid"'  is  merely  a  fluid  extract 
containing  the  regulation  amount  of 
drug  which  is  also  proved  by  assay  to 
exhibit  a  uniform  proportion  of  digitalin 
(total  glucosides). 

Tinctures.  —  "Concentrated"  and 
"specific"  tinctures  should  have  the 
same  strength  as  the  fluid  extract. 

The  tinctures  of  the  B.  P.  and  U.  S.  P. 
vary  slightly:  the  former  exhibits  a 
strength  of  3  to  24,  respectively,  of 
bruised  leaves  and  proof-spirit;  the  latter 
3  to  20,  of  drug  and  dilute  alcohol. 

The  ethereal  tincture  is  twice  the 
strength  of  the  U.  S.  P.  alcoholic  tinct- 
ure. 

Owing  to  the  rapid  deterioration  of 
digitalis-leaves  after  curing,  the  most  re- 
liable preparations  are  those  obtained 
from  responsible  homoeopathic  and  eclec- 
tic pharmacists,  both  being  in  duty 
bound  to  employ  the  fresh  leaves  of  the 
uncultivated  plant  in  its  second  season 
when  about  to  bloom.  The  homojo- 
pathic  pharmacist  chops  and  pounds  the 
leaves  to  a  pulp,  incloses  in  a  piece  of 
new  linen,  subjects  to  pressure,  and 
mixes  the  expressed  juice  by  brisk  agita- 
tion with  an  equal  amount,  by  weight,  of 
alcohol,  the  whole  being  then  allowed  to 
stand  for  eight  days  in  a  well-stoppered 
bottle  in  a  dark,  cool  place,  after  which 
it  is  filtered.  The  eclectic  macerates 
eight  ounces  of  fresh  leaves  in  a  pint  of 
alcohol  (7G°). 


DIGITALIS.    PRKPAKATIONS  AND  DOSES. 


469 


Active  fluid   preparations   of  digitalis 
do  not  lose  in  activity  by  being  made 
into  tablets,  nor  do  the  tablets  become 
less   active   by    keeping   than   do    other 
preparations  of  digitalis.    E.  M.  Hough- 
ton (Ther.  Gaz.,  Xo.  4,  p.  217,  '98). 
DiGiTALiN. — Digitalin,  as  it  formerly 
appeared  in  the  pharmacopojias,  is  now 
obsolete,  and  where  the  same  was  used 
as  the  title  of  a  concentration  it  is  now 
replaced  by  digitalisin.    The  latter  is  a 
very    uncertain    production    as    regards 
strength,  and  consequently  should  not 
be  employed. 

Vinegar. — Vinegar  of  digitalis,  which 
still  retains  a  place  in  some  Continental 
pharmacopreias,  offers  no  advantages 
over  other  fluid  preparations,  and  conse- 
quently has  been  dropped  by  the  British 
and  U.  S.  authorities. 

Liniment.  —  Digitalis-liniment  is 
merely  a  mixture  of  equal  quantities  of 
official  tincture  of  digitalis  and  soap- 
liniment. 

Ointment  and  Poultice. — Digitalis 
ointment  may  be  made  with  any  desir- 
able fat  and  of  any  required  strength, 
the  usual  proportions  are  1  to  9  of  solid 
extract  and  base,  respectively.  Digitalis 
poultice  may  take  the  form  of  a  fomenta- 
tion of  the  leaves,  or  be  made  by  adding 
an  ounce  of  the  tincture  to  a  linseed 
poultice. 

Active  Principles.  —  The  so-called 
active  principles  consist  of  a  number  of 
glucosides:  digitalin,  digitalein,  dig- 
itonin,  digitin,  and  digitoxin.  Unfort- 
unately, great  confusion  exists  regarding 
these  preparations,  which  has  been  fos- 
tered by  pharmacopoeial  errors.  Thus 
the  digitalin  of  ITomolle  &  Quevenne, 
recognized  by  French  authority,  is  an 
amorphous,  yellowish-white  powder,  in- 
odorous, intensely  bitter  to  taste,  ex- 
tremely irritating  to  the  nostrils,  and 
highly  poisonous;  it  is  sometimes  found 
n.^  small  scales.    It  is  chemically  a  mixt- 


ure of  the  digitalin  of  the  German  phar- 
macopoeia and  the  digitoxin  of  Schmiede- 
berg.  Another  form  that  has  the  sanc- 
tion also  of  the  French  Codex  is  digi- 
taliiie  (mark  the  final  e)  crislalliste,  or 
the  digitaleine  of  Nativelle,  and  appears 
as  white,  crystalline  tufts  or  needles,  and 
consists  almost  wholly  of  Schmicdeberg's 
digitoxin;  it  is  very  bitter  to  taste, 
slowly  eliminated  and  consequently 
cumulative  in  action,  and  dispensed  only 
when  "crystallized  digitalin"  is  ordered. 
Both  the  foregoing  are  insoluble  in  water 
or  ether,  but  the  crystallized  form  yields 
readily  to  chloroform  and  rectified  spirit. 

The  digitalin  of  the  German  Pharma- 
copoeia is  also  the  digitalin  verum  of 
Kiliani.  It  is  a  white  or  yellowish, 
amorphous  product,  consisting  of  digi- 
talein and  digitoxin  (Schmiedeberg's);  is 
soluble  in  water,  1  to  1000  in  alcohol; 
almost  insoluble  in  chloroform  and 
ether. 

Digitalein  (Schmiedeberg)  is  also  an 
amorphous,  yellowish-white  powder  of 
intense  bitter  taste;  soluble  in  water 
and  alcohol,  slightly  so  in  chloroform 
and  ether;  as  before  remarked,  this  is 
the  chief  constituent  of  German  digi- 
talin. 

Digitoxin. — The  digitoxin  glucoside 
of  Schmiedeberg  is  the  most  poisonous  of 
all  the  digitalis  principles  and  likewise 
markedly  cumulative  in  action,  owing  to 
the  difficulty  with  which  it  is  eliminated. 
It  occurs  as  a  white,  crj'stallized  powder, 
soluble  in  chloroform  and  alcohol, 
slightly  soluble  in  ether,  insoluble  in 
water. 

DiGiTONiN.  —  Soluble  in  water  and 
alcohol,  appears  in  the  form  of  yellow 
granules,  but  possesses  none  of  the  prop- 
erties for  which  digitalis  is  celebrated. 
It  appears  to  be  identical,  or  at  least 
closely  related,  to  saponin,  the  active 
principle  of  quilliai  bark. 


470 


DIGITALIS.     PHYSIOLOGICAL  ACTION. 


DiGiTix. — Digitin  is  a  coai-sely-granu- 
lated,  crj-stalline  powder,  soluble  in  alco- 
hol, ether,  and  alkaline  solutions,  and  is 
physiologicall}-  and  therapeiitically  inert. 
DIGITALIEESI^■'.  —  Digitaliresin  and 
digitoxiresin  purport  to  be  derivatives, 
respectively,  of  the  digitalin  and  digi- 
toxin  of  Schmiedeberg,  but  beyond  this 
nothing  is  known  of  either. 

A  comparative  study  of  digitalis  and 
its  derivatives  shows  that:  1.  Digitalis 
and  digitoxin  each  represent  the  full 
circulatory  powers  of  digitalis.  2.  Digi- 
talis, digitalin,  and  digitoxin  stimulate 
the  cardio-inhibitory  mechanism  both 
centrally  and  peripherally.  In  larger 
doses  they  paralyze  the  intrinsic  cardio- 
inhibitory  apparatus.  3.  They  all  cause 
a  rise  of  blood-pressure  by  stimulating 
the  heart  and  constricting  the  blood- 
vessels. 4.  Very  large  doses  paralyze  the 
heart-muscle  of  the  mammal,  the  organ 
stopping  in  diastole.  5.  Digitalin  of 
Jlerck  is  a  stable  compound,  1  gramme 
of  it  being  equivalent  to  about  70  cubic 
centimetres  of  tincture  of  digitalis.  G. 
Digitoxin  is  not  to  be  recommended  ior 
human  medication  on  account  of  its  irri- 
tant action,  which  makes  it  liable  to 
upset  the  stomach  when  given  by  the 
mouth,  or  to  cause  abscess  when  given 
hypodermically,  and  on  account  of  its 
insolubility,  which  renders  it  slowly  ab- 
sorbed and  irregularly  eliminated,  having 
a  marked  tendency  to  cumulative  action. 
Arnold  and  Wood  (Amcr.  Jour,  of  Med. 
Sciences,  Aug.,  1900). 

Digitalis  as  obtained  from  various  re- 
gions shows  entirely  regular  alterations 
at  dillercnt  periods  of  the  year.  These 
alterations  are  always  in  direct  associa- 
tion with  certain  definite  periods  of  the 
year,  the  general  result  being  that  the 
old  leaves  found  toward  the  beginning 
of  August  have  customarily  only  about 
one-fourth  the  activity  of  the  new 
leaves.  D.  Focke  (Zeits.  f.  klin.  Med., 
vol.  xlvi,  Nos.  5  and  6,  1902). 

When  digitoxin  is  employed,  it  is  rec- 
ommended that  a  solution  be  made  in 
alcohol,  chloroform,  and  water,  and  that 
it  be  administered  by  clyster:  digitoxin, 


V»s  to  Vei  grain;  chloroform,  4  minims; 
90-degree  alcohol,  1  drachm;  water,  to 
make  14  drachms;   at  one  dose. 

Physiological  Action. — Though  digi- 
talis per  se  has  been  before  the  medical 
profession  for  more  than  three  centuries, 
the  fact  remains  that  its  physiological 
attributes  are  by  no  means  thoroughly 
understood;  indeed,  they  constitute  a 
subject  on  which  there  is  great  differ- 
ence of  opinion.  It  may  be  affirmed 
that  experiments  upon  mammals,  birds, 
and  batrachians  have  added  practically 
nothing  to  the  knowledge  already  pos- 
sessed regarding  the  action  of  digitalis 
when  introduced  into  the  economy  of 
man.  Part  of  the  trouble  may  have 
arisen  from  the  fact  that  many  of  the 
preparations  as  found  in  shops  are  prac- 
tically inert,  while  the  different  dosage 
and  forms  of  exhibition  as  employed  by 
different  observers  inhibit  uniformity. 
The  action  on  the  two-chambered  heart 
of  the  frog,  or  three-chambered  heart  of 
the  bird,  both  of  which  animals  excrete 
solid  urea,  cannot  coincide  with  that  on 
the  four-chambered  heart  and  the  fluid- 
excreting  renal  gland  of  the  mammal, 
while,  as  is  well  known,  there  are  few 
drugs  toward  which  individual  mem- 
bers of  the  human  family  are  so  generally 
and  differently  idiosyncratic.  Again, 
the  actions  of  watery  and  alcoholic  prep- 
arations are  by  no  means  identical,  owing 
to  the  differences  in  the  solubility  of  the 
various  glucosides  in  these  menstrua;  an 
infusion,  for  instance,  holds  in  solution 
chiefly  the  digitonin,  while  tlie  tincture 
contains  digitalin  and  digitalein, — 
neither  contains  much  digitoxin,  but  the 
tincture  necessarily  carries  more  than 
tlie  infusion.  Notably  the  infusion  is 
more  directly  and  promptly  diuretic,  and 
the  B.  P.  tincture  more  so  than  that  of 
the  U.  S.  P.,  but  the  latter  two  afford 
the  best  results  when  the  heart  alone  is 


DIGITALIS.    PHYSIOLOGICAL  ACTION. 


471 


to  be  acted  on.  But  it  is  doubtful  if 
the  tincture  alone  ever  acts  as  a  true 
diuretic,  except  in  the  presence  of  a 
heart-lesion,  such  as  is  found  in  connec- 
tion with  some  form  of  hydrops.  The 
drug  often  fails  completely  in  securing 
the  desired  action  clinically,  because  the 
wrong  preparation  is  employed,  and  it 
may  here  be  noted  that  little  reliance  is 
to  be  put  on  the  glucosides,  at  least  not 
until  we  are  possessed  of  more  definite 
knowledge  regarding  their  composition 
and  physiological  relations.  Xot  only  is 
their  use  to  be  deprecated,  but  they  are 
generally  dangerous  and  sometimes  re- 
nedially  worthless.  Digitoxin  especially 
is  so  highly  toxic  and  so  difficult  of 
elimination  as  properly  to  bar  it  from 
official  recognition.  How  often  is  seen 
the  statement  that  digitalis  is  a  power- 
ful sedative,  and  again  that  it  is  a  heart- 
stimulant?  This  conveys  little  informa- 
tion, because  it  is  conflicting;  yet  it  may 
be  true,  and  depends  solely  upon  the 
dosage,  and  the  peculiarities  of  the  in- 
dividual patient.  In  fact,  there  is  no 
drug  in  the  materia  medica  that  requires 
more  careful  handling  or  more  careful 
study  of  effects  in  each  and  every  one 
for  whom  it  is  prescribed;  and  again 
there  is  no  drug  more  certain  in  secur- 
ing definite  results,  when  intelligently 
exhibited. 

Regarding  action  on  heart  and  circula- 
tion, it  is  deemed  best  to  give  in  abstract 
the  various  views: — 

Wood  sums  up  the  action  of  the  drug 
by  saying  that  in  moderate  doses  it  stimu- 
lates the  muscular  portion  of  the  heart 
(probably  of  its  ganglia),  increases  ac- 
tivity of  the  inhibitory  apparatus,  and 
produces  contraction  of  the  arterioles. 
As  a  consequence  of  the  first  action,  the 
cardiac  beats  become  stronger;  as  a  re- 
sult of  the  last,  there  is  narrowing  of  the 
blood-pnths,  and  to  the  passage  of  the 


vital  fluid  an  increased  resistance  which, 
acting  on  the  already-excited  inhibitory 
system,  aids  in  slowing  the  pulse.  De- 
cided therapeutic  doses  produce  great  re- 
duction and  sometimes  dicrotism  of  the 
pulse,  and  increase  the  size  and  force  of 
the  wave;  at  the  same  time  the  arterial 
tension  is  augmented. 

Murrell  states  that  the  greatest  and 
characteristic  action  of  the  drug  is  that 
it  affects  elasticity  of  cardiac  muscle 
without  at  first  modifying  its  contractile 
power,  as  indicated  by  increase  in  the 
volume  of  the  pulse,  although  the  abso- 
lute working  power  of  the  heart  is  neither 
increased  nor  decreased;  at  the  same  time 
the  quantity  of  blood  driven  into  the 
aorta  is  greater  than  before,  not  only  at 
every  beat  of  the  pulse,  but  even  in  a 
given  unit  of  time;  notwithstanding  the 
number  of  pulsations  be  diminished,  the 
result  is  a  better  filling  of  the  arteries 
and  an  increase  in  blood-pressure.  Ac- 
companying this  condition  there  is  slow- 
ing of  the  pulse  due  to  stimulation  of 
the  inhibitory  mechanism  of  the  heart. 
Finally,  in  conjunction  with  continuous 
high  pressure  there  is  irregularity  both 
in  the  action  of  the  heart  and  in  the  fre- 
quency of  the  pulse.  Digitalis  does  not 
exert  a  sedative  action  on  the  muscular 
substance  of  the  heart;  and  although  the 
organ  may  be  beating  more  slowly  it  may 
also  be  doing  more  work. 

Ringer  and  Sainsbury  teach  that  digi- 
talis undoiibtcdly  does  affect  directly — 
i.e.,  immediately — the  muscular  tissue  of 
the  heart,  including  persistent  contrac- 
tion. Inasmuch  as  this  action  on  the 
heart  is  independent  of  the  agency  of 
nervous  tissues,  it  seems  presumable  that 
it  may  affect  other  muscular  tissue  in  the 
same  way.  It  does  undoubtedly  cause 
strong  contraction  of  the  blood-vessels 
when  these  are  quite  cut  off  from  the  cen- 
tral nervous  control;   hence  it  must  act 


472 


DIGITALIS.    PHYSIOLOGICAL  ACTION. 


either  directly  on  the  muscular  tissue  of 
the  ■walls  of  blood-vessels  or  on  some  pe- 
ripheral nervous  apparatus  that  governs 
the  muscular  tissue  of  the  blood-vessels. 
In  therapeutic  use  it  may  be  conceived 
that  digitalis  ■will  act  in  different  ways: 
by  strengthening  the  action  of  a  weak 
heart;  by  reducing  the  strength  of  the 
beats  of  a  heart  acting  too  powerfully; 
by  lessening  the  frequency  of  the  heart's 
beats;  by  correcting  irregular  action  of 
the  organ;  by  increasing  tonicity  and 
BO  lessening  the  size  of  the  cavities, 
thereby  obviating  the  condition  of  over- 
distension in  which  the  stretched  ven- 
tricles are  unable  to  contract  upon  the 
contents,  a  condition  threatening  com- 
plete asystole — the  second  of  these  prop- 
ositions a  different  and  fuller  dosage  will 
probably  be  required. 

It  has  been  the  general  view  that 
each  preparation  is  capable  of  producing 
effects  peculiar  in  some  respects  to  itself. 
But  the  physiological  effects  of  digi- 
talein  and  digitoxin  are  identical  with 
those  of  digitalin,  except  that  they  do 
not  stimulate  the  vasomotor  centre  or 
the  pneumogastric  apparatus,  and  so  do 
not  directly  raise  blood-pressure  or  slow 
the  heart.  In  other  ■nords,  they  increase 
the  force  of  ventricular  contraction.  The 
effect  of  digitonin  is  to  depress  the 
vagus  nerves,  so  it  antagonizes  the  vagal 
effect  of  tlie  digitalin  and  prevents  digi- 
talis from  slowing  the  heart  to  the  ex- 
tent that  would  result  from  the  use  of 
digitalin  alone.  It  also  depresses  the 
heart-muscle.  H.  A.  Hare  (Therap.  Gaz., 
Aug.  10,  '07). 

Attention  called  to  the  vasomotor  ac- 
tion of  digitalis;  with  a  rather  generous 
dose,  migraine  due  to  cerebral  congestion 
can  be  overcome,  where  a  small  dose, 
acting  on  the  circulatory  centre,  would 
fiimpty  aggravate  the  condition.  Diuresis 
is  produced  only  in  those  cases  in  which 
there  is  anasarca,  and  is  due  to  ana- 
sarca; often  there  is  diuresis  without 
increase  of  blood-pressure.  When  the 
dropsy  lias  di.sappoared  the  diuresis 
ceases.    Diminution  of  the  dose  is  indi- 


cated on  the  disappearance  of  dropsy. 
Chief  indications  of  digitalis  are  in- 
creased frequency  and  irregularity  of  the 
pulse  and  the  presence  of  cedema.  In 
cases  the  reverse  of  these  it  is  useless 
or  harmful.  AVarning  is  given  against 
its  careless  use  in  myocarditis  with  fatty 
degeneration  and  in  cardiac  asthenia 
with  dilatation.  In  cardiac  dilatation  of 
gastric  origin  digitalis  is  harmful,  for  it 
is  not  tolerated  by  the  stomach.  Ar- 
teriosclei'osis  is  not  a  contra-indication 
if  caution  is  used,  ^^^lere  increased  fre- 
quency of  the  pulse  or  dropsy  are  pres- 
ent in  aortic  insufficiency,  digitalis  is 
distinctly  indicated.  The  same  is  true 
in  mitral  stenosis.  In  mitral  insuffi- 
ciency it  has  its  widest  use,  but  it  la 
late  in  the  disease  that  digitalis  is  most 
needed.  ^AHien  tricuspid  accompanies 
mitral  insufficiency,  the  former,  unless 
great  care  be  taken,  is  made  to  disappear 
too  rapidly  by  digitalis,  and  pulmonary 
apoplexy  results,  through  increase  of 
capillary  pressure.  Of  the  preparations, 
digitalin  is  preferable.  M.  Potani  (Jour, 
de  Mfd.,  '9S). 

The  chemical  composition  of  digitalis 
is  complex,  some  of  its  active  principles 
antagonizing  others;  the  various  prepa- 
rations of  digitalis  differ  widely  in  their 
composition  and  action;  the  so-called 
cumulative  action  of  digitalis  is  due  to 
its  contracting  the  arterioles  and  shut- 
ting off  nutrition;  it  is  both  a  useful 
and  a  dangerous  remedy,  and  has  a  very 
limited  range  of  usefulness ;  it  is  of  use 
only  in  lesions  of  the  mitral  valve,  and 
then  only  for  a  short  time,  and  should 
be  discontinued  as  soon  as  those  have 
been  overcome;  it  is  of  value  as  a  di- 
uretic only  when  there  are  low  arterial 
tension  and  engorgement  of  the  kidney. 
Digitalis  decreases  the  excretory  action 
of  the  normal  kidney  and  impairs  its 
nutritive  activity.  The  tincture  of  digi- 
talis, made  from  the  fresh  leaves,  is  the 
most  valuable  and  the  most  certain  of 
the  preparations  of  digitalis.  It  eon- 
tains  the  largest  percentage  of  those 
constituents  which  are  moat  useful  in 
the  treatment  of  cardiac  disease.  W.  H. 
Porter  (Amor.  Medicine,  Apr.  27,  1000). 

Investigations  carried  on  in  the  Phar- 
macological Institute  in  Heidelberg,  and 


DIGITALIS.    PHYSIOLOGICAL  ACTION. 


473 


based  on  experiments  on  cats  witli  dif- 
ferent pure  preparations  of  digitalis,  the 
influence  of  each  drug  being  continued 
for  a  period  of  several  weeks.  All  dig- 
italis preparations  were  used  in  grad- 
ually increased  doses.  At  first  a  simple 
therapeutic  action  occurred,  which  finally 
became  cumulative.  Digitoxin  exhibited 
the  strongest  cumulative  action,  and  is, 
therefore,  not  to  be  recommended  for 
continued  daily  use.  Digitalicum,  on  the 
other  hand,  is  rapidly  excreted,  and  may 
be  used  in  certain  cases  for  considerable 
periods.  Strophanthin  is  usually  more 
evanescent  in  its  action  than  digitalis, 
but  a  preparation  of  strophanthin  re- 
cently prepared  by  Professor  Thorns,  of 
Berlin,  is  particularly  active  and  lasting. 
In  none  of  the  preparations  was  there 
observed  any  tendencj'  to  become  habit- 
uated to  the  drug.  Frankel  (Amer. 
Medicine,  May  31,  1902). 

Action  on  Brain  and  Cord. — It  is 
now  generally  held  that  digitalis,  in 
therapeutic  doses,  has  little  effect  upon 
either  the  brain  or  the  spinal  cord,  but 
earlier  writers  laid  great  stress  upon  its 
"mildly-irritant"  properties  as  regards 
both,  and  that  as  it  became  cumulative 
it  tended  to  "confuse  the  mental  fac- 
ulties." There  are  some  observers  who, 
to  this  day,  ascribe  the  antithermic  ac- 
tion of  the  drug  to  an  effect  upon  the 
cord,  whereas  it  becomes  an  antipyretic 
solely  by  its  influence  upon  the  circula- 
tion. In  pyrexias  there  is  partial  vasom- 
otor paralysis  with  dilated  arterioles,  low 
blood-pressure,  and  increased  tissue- 
change  in  and  around  the  dilated  ter- 
minal vessels;  consequently  by  contract- 
ing these  vessels  digitalis  raises  blood- 
pressure,  it  being  well  understood  that, 
as  the  latter  takes  place,  the  tempera- 
ture falls,  and  vice  versa.  In  other  words, 
there  is  always  an  antagonism  between 
temperature  and  blood-pressure. 

While  ordinary  doses  do  not  affect  the 
brain,  as  the  drug  becomes  cumulative, 
or  it  is  pushed  to  a  point  approaching 


toxicity,  the  reflexes  of  the  spinal  cord 
seem  to  be  somewhat  lessened.  As  be- 
fore shown,  under  ordinary  dosage,  there 
is  probably  some  stimulation  of  the 
vasomotor  and  pneumogastric  nerves. 

Action  on  Urinary  Apparatus. — 
Under  certain  conditions  digitalis  seems 
to  increase  the  flow  of  urine  without 
altering,  in  any  essential  respect,  the 
quantity  or  proportion  of  its  solid  in- 
gredients; but,  strange  to  say,  this  ac- 
tion is  seldom  manifested  in  the  healthy 
human  subject,  though  it  is  apt  to  be 
very  pronounced  when  there  is  an  accu- 
mulation of  fluid  to  be  removed.  In 
truth,  the  manifestations  of  digitalis  are 
often  inconsistent  and  varying  as  regards 
renal  secretion,  and  are  probably  in 
great  measure  indirect  and  secondary. 
As  before  intimated,  the  infusion  is  the 
most  reliable  form  to  exhibit  for  such 
purpose,  and  doubtless  here  the  watery 
menstruum  should  receive  a  due  portion 
of  credit.  That  the  drug  is,  in  any  sense, 
adenagic  or  a  stimulant  to  glandular  tis- 
sue, and  consequently  diuretic  because 
of  such  action,  receives  little  credence 
these  days.  A  fairly  free  use  of  alco- 
holics in  connection  with  the  infusion 
seems  to  enhance  the  activity  of  dig- 
italis as  regards  the  kidneys,  but  a  better 
method  is  to  combine  with  the  latter  a 
minute  portion  of  cantharides. 

Digitalis  has  no  pronounced  constant 
elTect  upon  nitrogenous  elimination. 
Alexeevsky  (St.  Peter.,  Inaug.  Diss.,  '00). 

The  drug  increases  the  consumption  of 
the  chlorides,  sulphates,  and  phosphates. 
Beljakow  (Schmidt's  Jahrb.,  B.  219,  '91). 

Digitalis  increases  the  amount  of 
solids  eliminated  in  the  urine,  except 
urea  and  uric  acid,  which  are  diminished 
under  its  use.  Biddle  ("Mat.  Med.  and 
Therap.,"  '95). 

Conclusions  regarding  physiological 
and  therapeutic  actions  of  digitalis  and 
of  its  active  principles  summarized  as 
follows:     1.  The  physiological  action  of 


474 


DIGITALIS.    PHYSIOLOGICAL  ACTION. 


digitalis  is  exerted  chiefly  (a)  on  the 
heart,  (6)  on  the  blood-vessels,  and  (e) 
on  the  secretion  of  urine.  2.  Its  action 
on  the  heart  is  that  it  (a)  slows  the  car- 
diac beats  chiefly  by  stimulation  of  the 
roots  of  the  vagus  in  mammals,  (6)  in- 
creases the  force  of  systole,  and  (c)  in- 
creases the  extent  of  expansion  in  dias- 
tole. Both  &  and  c  are  due  to  an  action 
on  the  cardiac  muscle.  3.  It  contracts 
the  peripheral  vessels,  and  thus  slows  the 
current  of  blood  through  them.  4.  By 
its  combined  action  of  contracting  the 
peripheral  vessels  and  of  increasing  the 
power  of  the  heart  it  raises  the  blood- 
pressure.  5.  The  diuresis  which  digitalis 
produces  is  chiefly  due  to  increase  of 
blood-pressure.  6.  Digitalis  contracts  the 
arterioles  in  the  kidney  sooner  than 
those  in  other  parts  of  the  body.  The 
renal  vessels  may  contract  so  much  as  to 
arrest  the  secretion  of  urine  altogether, 
although  the  general  blood-pressure  is 
high.  7.  When  blood-pressure  is  already 
high,  digitalis  cannot  be  expected  to  have 
a  powerful  diuretic  action;  but  if  the 
blood-pressure  be  low,  from  natural  con- 
stitution or  disease,  digitalis  will  have  a 
diuretic  action.  8.  Digitalis  is  a  local 
antesthetic,  but  also  produces  pain.  It 
therefore  belongs  to  the  class  termed  by 
Liebreich  "ansesthctical  dolorosa."  9.  In 
large  or  in  accumulated  doses  it  gives 
rise  to  gastric  irritation.  10.  The  action 
of  digitalis  is  due  to  digitalin,  digitalein, 
and  digitoxin.  These  principles  all  have 
an  action  similar  in  kind,  but  differing 
in  degree.  11.  The  therapeutic  actions  of 
digitalis  and  of  its  active  principles  are 
that  they  («)  regulate  the  heart's  action, 
(6)  assist  a  failing  circulation,  and  (c) 
act  as  diuretics.  12.  The  regulating  ac- 
tion of  digitalis  is  useful  in  palpitation 
and  functional  disturbances  of  rhythm. 
l.'.  The  most  important  use  of  digitalis 
and  of  its  active  principles  is  in  the 
treatment  of  mitral  incompetence  due 
cither  to  disease  of  the  valves  or  dihita- 
tion  of  the  ventricle.  14.  In  cases  of 
aortic  regurgitation  digitalis  is  (a)  un- 
nccPBsary  and  not  without  danger  when 
compensation  is  complete,  but  (b)  very 
useful  when  compensation  fails.  15. 
When  the  blood-pressure  is  already  high, 
digitalis  may  be  injurious  by  increasing 


it  still  farther,  and  thus  causing  symp- 
toms of  angina  pectoris  or  tending  to 
produce  apoplexy.  T.  Lauder  Brunton 
(Inter.  Hed.  Congress;  Brit.  Med.  Jour., 
Sept.  29,  1900). 

As  a  diuretic,  digitoxin  is  superior  to 
digitalin,  since  it  actually  dilates  the 
renal  vessels,  while  stimulating  the 
heart.  Furthermore,  its  action  is 
prompter  and  more  certain  than  that 
of  digitalin.  It  manifests  its  efl'ects 
oftentimes  within  twelve  hours,  and  is 
less  liable  to  cumulative  action  than 
digitalin.  JIasius  has  used  as  much  as 
Vw  grain  a  day.  After  discontinuing 
the  use  of  the  drug  the  influence  of 
digitoxin  is  said  to  persist,  sometimes, 
for  eight  to  ten  days.  To  avoid  di- 
gestive disturbance,  Wenzel  employed 
it  chiefly  by  enema,  giving  about  V»o 
grain  in  10  minims  of  alcohol  and  4 
ounces  of  water.  The  action  upon  the 
heart,  as  observed  in  these  experiments, 
was  quite  pronounced;  at*  first  three 
rectal  injections  were  given  daily  (pre- 
vious thorough  cleansing  of  the  bowel 
being  presupposed),  afterward  only  two 
injections  were  used,  and,  finally,  only 
one  was  found  necessary,  in  order  to 
maintain  the  first  efl'ect  produced.  In 
personal  experience  digitoxin  has  been 
given  in  a  series  of  cases — of  late,  chiefly 
hypodermieally,  but  also  by  the  mouth 
{always  after  meals).  It  was  the  ex- 
ception to  see  any  digestive  disturbance 
when  '/too  grain  or  less  of  digitoxin  was 
being  given  three  times  daily.  In  no 
case  did  an  abscess  ever  result  from  the 
hypodermic  syringe. 

Digitoxin  has  been  especially  recom- 
mended in  chronic  myocarditis  and  in 
eases  of  ruptured  compensation. 

A  solution  of  digitoxin  is  liable  to 
precipitate  on  coming  in  contact  with 
tlie  secretions  of  the  body.  To  avoid 
this,  and  yet  not  use  too  much  alcohol 
in  the  pliarmacoutical  preparation  of 
the  solution,  it  has  boon  recoinmondod 
to  add  a  little  chloroform  to  the  solu- 
tion. The  following  solution  has,  after 
experimentation,  been  found  to  bo 
stable,  and  will  not  precipitate  upon 
contact  with  blood-scrum,  water,  or 
Bodiumchlorido  solution:  — 


DIGITALIS.    IXCOMPATIBLE.S.     POISOXIXG. 


475 


I^  Digitoxin,  ■■/.„  grain. 
Chloroform,  1 '/:  minims. 
Alcohol  at  00  per  cent.,  23  minims. 
Water,     sufficient     to     make     'A 
ounce. — M. 
L.  L.  Solomon  (N.  Y.  Med.  Jour.,  Feb. 
9,  1901). 

Action  as  an  Antipyretic. — Why 
toxic  doses  cause  a  fall  of  temperature, 
even  in  health,  is  one  of  the  physiolog- 
ical problems  that  yet  awaits  solution; 
and  with  this  depressed  temperature 
muscular  paralysis  is  apt  to  supervene. 

Action  on  Uterus. — The  muscular 
substance  of  the  uterus  is  powerfully 
contracted  by  digitalis.  It  was  long  sup- 
posed that  this  action  was  the  result  of 
stimulation  of  uterine  ganglia,  but  it  is 
now  believed  to  be  due  to  the  affinity  of 
the  drug  for  unstriped  muscular  fibre. 
In  uterine  ha?morrhage,  when  admin- 
istered, the  patient  (usually  in  about  ten 
minutes)  complains  of  very  severe  pain 
in  the  region  of  the  sacrum,  which 
passes  into  the  hypogastrium,  and  in 
every  respect  seems  to  resemble  the  pain 
of  the  first  stage  of  labor;  very  shortly 
afterward  a  considerable  quantity  of 
blood,  generally  in  part  coagulated,  is 
forced  out  from  the  womb. 

As  digitalis  has  been  employed  some- 
what extensively  and  successfully  in  sim- 
ple monorrhagia,  its  affinity  for  the  re- 
productive apparatus  of  the  female  seems 
well  established;  some  authors  go  so  far 
even  as  to  accredit  it  with  phenomenal 
emmenagogic  properties,  though  the 
evidence  adduced  appears  to  be  of  rather 
a  hazy  and  uncertain  character;  and  yet 
digitalis  is  employed  as  an  ecbolic  or 
abortifacient  in  some  European  coun- 
tries. 

Incompatibles.  —  Digitalis  is  incom- 
patible in  fluid  preparations  with  salts 
of  iron  and  lead;  likewise  with  tannin 
and  all  vegetable  solutions  containing 
them.    Therapeutically  it  is  antagonized 


by  aconite  and  its  alkaloid,  by  scoparine, 
muscarine,  saponin,  staphisagria  and  the 
alkaloid  of  the  latter,  delphinine,  and  by 
drugs  of  the  belladonna  group. 

Digitalis  Poisoning.  —  Digitalis  poi- 
soning is  of  extremely  rare  occurrence: 
a  fact  that  may  be,  oftener  than  not, 
perhaps,  ascribed  to  the  practically-inert 
character  of  most  of  the  preparations 
marketed.  The  symptoms  are,  for  the 
most  part,  the  same  as  when  too  large  or 
too-long-continued  doses  have  been  ex- 
hibited, but  in  greatly-aggravated  degree: 
disordered  state  of  prima;  vice;  slow  and 
irregular  pulse;  coldness  of  extremities; 
syncope  or  tendency  thereto;  giddiness; 
confusion  of  vision,  external  objects  ap- 
pearing of  yellow  or  green  hue,  mist  or 
sparks  before  eyes,  which  are  prominent, 
with  pupils  fixed  and  perhaps  dilated; 
weight  and  pain  in  forehead;  weakness 
of  limbs;  insomnia;  stupor  or  delirium; 
urine  suppressed,  perhaps;  there  may  be 
abundant  salivation.  Fatality  is  usu- 
ally preceded  by  stupor  or  convulsions 
and  a  dilated,  insensible  pupil. 

According  to  Tardieu,  an  almost  diag- 
nostic symptom  of  digitalis  poisoning  is 
a  blue  color  of  the  sclerotic. 

The  minimum  fatal  dose  of  digitalis 
is  not  known,  and,  owing  to  the  incon- 
sistency of  its  action,  probably  never 
will  be.  The  treatment  after  evacuat- 
ing stomach  and  bowels  should  be  tan- 
nin, opium,  stimulants,  and  recumbent 
posture;  aconite  may  be  employed,  but 
it  requires  to  be  administered  with  cau- 
tion. 

Treatment  of  digitalis  poisoning  must 
be  symptomatic.  The  administration  of 
the  drug  is  to  be  stopped;  the  ali- 
mentary canal  is  to  be  cleared  of  any 
impurities  it  may  contain;  elimination 
must  be  increased  by  diluents;  sickness 
allayed;  arterial  tension  reduced  when 
high;  sleep  procured  if  necessary,  and 
other  symptoms  treated  as  they  arise. 


476 


DIGITALIS.    THERAPEUTICS. 


Xitroglyeerin  is  the  best  remedy  for  the 
reduction  of  arterial  tension.  If  the 
blood-pressure  is  low,  alcohol  will  prove 
of  great  senice.  Taylor  and  Marshall 
(Brit.  Med.  Jour.,  Nov.  4,  '99). 

After  the  drug  had  been  administered 
to  a  woman  of  40  for  six  weeks  (5  drops 
of  the  tincture  every  four  hours),  symp- 
toms of  profound  mental  disturbance 
appeared.  At  first  simulating  mere  hys- 
terical excitement,  the  disorder  rapidly 
developed  into  a  violent  mania.  The 
drug  was  immediately  discontinued,  and 
she  recovered  promptly.  A.  W.  Dunning 
(St.  PaiU  Med.  Jour.,  May,  1902). 

In  spite  of  a  vast  amount  of  evidence 
adduced  in  favor  of  medicinal  use  of  the 
glucosides  of  digitalis,  the  fact  remains 
that  all  are  uncertain  bodies,  and  that 
no  one  definitely  represents  the  thera- 
peutic activity  of  the  drug  itself.  They 
are  practically  worthless  in  heart  dis- 
eases. Even  for  hypodermic  use  tincture 
of  digitalis  is  preferable  and  it  is  less 
irritating.  In  any  event,  the  only  glu- 
cosides worthy  of  attention  are  the  dig- 
italeine  of  Nativelle,  or  d.  cristalUsee, 
and  the  digitoxin  of  Schmiedeberg;  even 
these  are  highly  irritant  to  the  skin  and 
likely  to  produce  eczematous  and  other 
eruptions  that  are  also  often,  as  well, 
results  of  the  use  of  digitalis  ointments 
or  poultices. 

Some  nocturnal  delirium  is  one  of  the 
first  bad  results  of  digitalis.  Pallor, 
coldness  of  the  extremities,  trembling, 
and  contraction  of  the  pupils  are  im- 
portant indications  to  suspend  the  drug. 
Some  patients  die  suddenly  of  syncope, 
others  gradually.  Deatli  from  digitalis 
is  most  frequently  met  with  in  Brighl's 
disease,  artliritic  and  ana:mic  subjects, 
and  in  persons  with  aortic  incompetence 
or  delirium  tremens.  Occasionally  there 
is  melancholia  and  niglit-tcrrors.  An 
unusual  result  is  pulmonary  apoplexy. 
Potdin   (.Tour,  de  Mf-d.,  Apr.  10,  1900). 

Therapeutics. — Digitalis  is  one  of  the 
niost  abused  drugs  of  the  materia 
medica. 


One  of  the  most  universal  abuses 
is  the  habit  of  prescribing  it  for  a  pa- 
tient without  advising  him  to  abstain 
from  exercise  while  under  its  influence. 
There  are  very  few  physicians  who  have 
not  been  disappointed  by  its  results  from 
the  counteracting  influence  of  exercise. 
All  patients  taking  digitalis  should 
live  in  perfect  physical  and  mental 
quietude,  as  otherwise  there  is  danger 
of  adding  to  the  perils  of  the  diseased 
conditions  demanding  its  use.  English 
(Med.  and  Surg.  Rep.,  Aug.  22,  '96). 

In  disease,  rest  in  bed  and  a  regular 
diet  will  alone  cause  diuresis  in  60  per 
cent,  of  cases  in  from  2  to  5  days.  The 
ureal  excretion  is  similarly  increased. 
In  2G  cardiac  cases  treated  by  digitalis 
an  increase  in  excretion  of  solids  and 
fluids  took  place  in  22  eases,  and  the  best 
results  were  obtained  from  the  tincture, 
15  minims  every  four  hours,  or  from 
Nativelle's  granules,  one  three  times  per 
day.  Out  of  13  cases  in  which  strophan- 
thus  was  used,  S  showed  diuretic  effects, 
thougli  not  so  marked  as  from  digitalis, 
and  much  more  disagreeable  gastro- 
intestinal symptoms  followed.  Diuretin 
increased  the  urine  in  6  out  of  12  cases, 
its  advantage  being  the  rapidity  of  its 
action,  but  its  toxic  symptoms  were  more 
marked  than  digitalis  and  its  effect  less 
prolonged.  In  Briglit's  disease,  however, 
it  acts  more  favorably  than  digitalis  or 
strophanthus.  In  cardiac  dropsy  digi- 
talis is  the  drug  par  cxceUcnce.  J.  A. 
MacCaren  (Med.  Cliron.,  Sept.,  1900). 
Diseases  of  the  Heart. — Digitalis 
is,  above  all,  a  cardiac  remedy;  but  there 
is  as  much  dispute  over  the  classes  of 
cases  to  which  it  is  applicable  as  over  its 
physiological  action. 

In  pediatric  practice  digitalis  is  indi- 
cated in  cardiac  disease  whenever  the 
nuiscular  contractions  become  of  insuffi- 
cient strength.  It  is  especially  valuable 
in  mitral  disease,  but  is  contra-indicated 
in  aortic  insufTicicncy  until  the  pulse  be- 
comes rapid  and  irregular.  It  is  useful 
for  its  diuretic  action  in  respiratory  dis- 
ease, like  liydrothorax  and  i)leurisy,  and 
for  its  effect  upon  the  heart  in  pneu- 
iiHiiiia,  severe  bronchitis,  and  influenza. 
In  repeated  severe  luemoptysis  it  is  of 


DIGITALIS.    THERAPEUTICS. 


477 


value.  In  acute  infectious  diseases  it  is 
valuable  if  given  before  the  myocardium 
has  undergone  marked  degeneration.  It 
should  never  be  given  for  a  longer  period 
than  7  or  8  consecutive  days,  and  then 
its  use  must  be  suspended  for  from  8  to 
10  days.  Comby  (Kevue  Inter,  de  Jl6d., 
etc.,  vol.  ix,  No.  11,  '99). 

Digitalis  is  especially  indicated  in 
simple  dilatation.  It  is  not  contra- 
indicated  except  in  the  advanced  stages 
of  myocardial  degeneration.  Huchard 
(Mf'd.  Mod.,  Feb.  17,  1900). 

Insufficient  attention  is  paid  to  the 
selection  of  suitable  patients  for  digitalis. 
When  inequality,  irregularity,  and  insuf- 
ficiency of  the  pulsations  are  absent,  or 
when  there  is  no  dropsy  of  the  cellular 
tissues  and  serous  cavities,  contra-indica- 
tion  for  digitalis  exists.  A  permanently 
infrequent  pulse  is  not  a  eontra-indica- 
tion.  A  strong  contra-indication  to  digi- 
talis is  the  presence  of  myocardial  lesions. 
Tlius  myocarditis,  senile  cachexia,  fatty 
degeneration,  etc.,  call  for  the  very 
greatest  care  in  the  use  of  this  drug. 
Aortic  incompetence  is,  generally  speak- 
ing, a  contra-indication.  Dyspepsia  very 
often  causes  digitalis  to  disagree.  A  ca- 
chectic condition  is  a  contra-indication. 
Potain  (Jour,  de  M6d.,  Apr.  10,  1900). 

The  underlying  principle  which  should 
govern  the  clinical  use  of  digitalis  is  its 
iiidiiect  influence,  tliroiiyh  Uie  adrenals, 
on  the  heart  and  vasomotor  system. 
The  practical  bearing  of  this  principle 
may  be  illustrated  by  the  following  few 
examples: — 

1.  In  uncomplicated  dilatation  of  the 
heart,  failure  of  the  cardiac  muscle  to 
contract  adequately,  i.e.,  in  loss  of  car- 
diac poiecr,  the  secretion  of  the  adrenals 
would  logically  be  indicated,  since  we 
have  seen  that,  as  does  suprarenal  ex- 
tract, it  increases  this  power  to  a  greater 
degree  than  any  agent  known.  We 
know  that  this  is  precisely  where  digi- 
talis is  at  its  best,  particularly  when 
the  riijht  heart  is  dilated — the  side  first 
reached  by  the  adrenal  secretion. 

2.  The  word  "uncomplicated"  must  be 
qualified  here,  however.  We  have  a 
valvular  lesion  with  dilatation,  the 
heart  doing  its  best  to  do  its  work 
notwithstanding   the    obstruction.     Yet 


the  incTcased  resistance — mitral  in  most 
cases — keeps  it  dilated,  and  the  organ  ia 
already  showing  slight  signs  of  hyper- 
trophy. It  requires  help — more  "dy- 
namism," as  Brown-.S(5quard  called  it 
fifty  years  ago  when  he  advanced  the 
view  that  the  main  factor  of  the  heart's 
contractile  energ}-  was  in  its  venous 
blood.  What  greater  help  could  we  give 
it  than  the  secretion  of  the  adrenals,  its 
main  source  of  contractile  power? 
Digitalis,  we  know,  is  of  great  value 
in  just  such  cases. 

3.  Mitral  stenosis  or  insufficiency  are 
types  of  cardiac  disorders  to  which  ref- 
erence has  just  been  made.  Yet  in 
many  instances  the  valves  of  both  sides 
of  the  heart  are  diseased  and  passive 
resistance  to  the  admission  of  blood  to 
the  right  heart  occurs,  causing  passive 
hyperaemia  and  venous  stasis.  The  se- 
cretion of  the  adrenals  raises  the  gen- 
eral vascular  pressure,  thus  forcing 
more  blood  toward  the  heart;  and  slows 
cardiac  action, — thus  giving  it  more 
time  to  dilate  and  to  admit  more  blood. 
The  relief  digitalis  affords  in  such  cases 
is  well  known. 

4.  Conversely:  We  have  to  deal  with 
a  heart  which  has  reached  the  stage  of 
full  compensation:  i.e.,  hypertrophy. 
It  has  succeeded — too  well  perhaps — in 
mastering  the  valvular  obstruction  in 
the  sense  that  it  has  acquired  the  power 
of  forcing  a  relatively  adequate  pro- 
portion of  blood  past  the  obstruction. 
Would  an  increase  of  adrenal  secretion 
in  the  blood,  which  would  raise  the  vas- 
cular pressure,  i.e.,  the  peripheral  re- 
sistance to  the  circulation  of  blood,  and 
thus  increase  the  labor  of  the  heart, 
benefit  such  a  case?  We  know  that 
digitalis  is  harmful  under  these  condi- 
tions, and  that  it  can  actually  promote 
hypertrophy. 

5.  The  case  is  one  of  arteriosclerosis, 
with  more  or  less  advanced  calcification 
of  the  aorta  and  of  the  coronaries  per- 
haps, and  also  of  a  few  or  many  arter- 
ies (of  undeterminable  limits  in  the  liv- 
ing subject). — all  complicating  a  cardiac 
disorder.  The  pulse  is  hard  and  small, 
indicating  circulatory  resistance  some- 
where. The  secretion  of  the  adrenals, 
which    increases    the    general    vasocon- 


478 


DIGITALIS.    THEEAPEUTICS. 


striction  and,  simultaneousl!),  the  power 
of  the  heart's  contractions,  thus  greatly 
augmenting  the  centrifugal  pressure 
of  the  blood-stream,  is  therefore  indi- 
cated. Digitalis  is  known  to  be  unsafe 
in  such  cases. 

6.  The  case  is  one  of  aortic  regurgita- 
tion. Owing  to  a  lesion  of  the  aortic 
valves,  a  reflux  of  blood  into  the  ven- 
tricle occurs  during  diastole.  The  ad- 
renal secretion,  by  slowing  the  heart, 
lengtlieus  the  diastole  and  affords  more 
time  for  regurgitation;  again,  by  caus- 
ing general  vasoconstriction,  it  increases 
the  resistance  to  the  blood-current  and 
helps  to  detain  the  blood  in  the  ven- 
tricle. It  tends  greatly,  therefore,  to 
increase  the  trouble — as  does  digitalis. 
Charles  E.  de  M.  Sajous  (Monthly  Cy- 
clo.  of  Praet.  Med.,  Sept.,  1904). 

In  arteritis  digitalis  is  a  powerful 
auxiliary,  assisting  to  control  the  mor- 
bidly increased  action  of  the  heart  and 
arteries,  but  it  should  not  be  used  to 
the  exclusion  of  general  antiphlogistic 
measures. 

Some  consider  digitalis  is  beneficial  in 
mitral  obstruction,  while  others  hold  it 
is  indicated  more  especially  in  mitral  re- 
gurgitation. It  has  been  observed  of 
eminent  service  in  cases  where,  after 
death,  the  symptoms  were  seen  to  be 
due  to  mitral  regurgitation,  and  little,  if 
at  all,  to  mitral  obstruction.  One  should 
try  digitalis  in  every  mitral  case,  even  in 
pure  mitral  stenosis.  Inefficiency  may 
be  due  to  irregularity  arising  from  fatty 
degeneration ;  and  the  indications  for 
its  use  are  less  conspicuous  in  aortic 
disease  with  insufficient  compen.sation 
than  in  purely  mitral  cases,  though  in 
failinj,'  lieart  from  aortic  disease  it  may 
render  excellent  service.  In  iiTitable 
heart  where  much  hypertrophy  exists, 
digitalis  may  prove  serviceable,  and  may 
totally  fail  to  afford  any  relief.  It  is 
often  valualjle  in  quelling  attacks  of  pal- 
pitation. It  is  useful  in  fatty  heart  and 
arterio-capillary  fibroses  inducing  hy- 
pertrophy of  left  ventricle.  Ringer  and 
Sainsbury  ("Iland-ljook  of  Therap.," 
-97). 


ANEUEisii  AND  ATHEROMA. — A  num- 
ber of  writers  have  lauded  the  use  of 
digitalis  in  aneurisms  and  in  general 
capillary  atheroma,  with  a  view,  as 
stated,  of  "quieting  the  circulation." 
Such,  however,  must  be  considered  as 
open  to  severe  censure,  since  increased 
blood-pressure  maj%  in  the  one  case, 
tear  open  the  thin  wall  of  the  aneurismal 
sac,  and  in  the  other  rupture  an  ather- 
omatous cerebral  capillary. 

If  there  be  increased  resistance  to  the 
circulation  in  aneurism  or  in  general 
capillary  atheroma,  and  the  heart  has 
not  sufficient  power  to  meet  this,  digi- 
talis may  be  useful,  but  must  be  em- 
ployed with  extreme  caution.  H.  C. 
Wood  ("Princ.  and  Prac.  of  Therap.," 
'94). 

Contra-indicated  because  it  increases 
intra-arterial  pressure.  Roth  ("^Modern 
Mat.  Med.  and  Therap.,"  '95). 

Digitalis  is  contra-indicated  in   aneu- 
rism   and   all   diseases   accompanied   by 
high     tension,     and     where     there     are 
changes  in  cardiac  muscle  or  atheroma 
of   blood-vessels,   except   for   temporary 
use     in     emergency.       Foster      ("Prac. 
Therap.,"  vol.  i,  '90). 
Deopst;    Hydrocephalus. — In   the 
dropsy  of  visceral  disease  and  in  the 
serous   accumulations    of   inflammatory 
origin  digitalis  is  often  of  service,  but 
preferably  it  should  be  used  in  connec- 
tion with  some  other  diuretic,  such  as 
broom  or  squill;    a  minute  portion  of 
cantharides  added  to  digitalis  infusion 
insures    a    satisfactory    diuretic    effect. 
But  the  best  results  invariably  accrue  to 
administrations  in  the  dropsy  of  cardiac 
disease  and  subacute  nephritis.     In  the 
United  States  the  remedy  has  never  been 
employed    with    the    same    freedom    as 
abroad;    and  in  England  and  Scotland 
patients  were  formerly — and  even  yet  in 
some  districts — fairly  drenched  with  an 
infusion  made  with  "two  handfuls"  of 
leaves,  drank  ad  libitum  until  ultimatvj 
narcosis,    vomiting,    and    purging    oc- 


DIGITALIS.    THEKAPEUTICS. 


479 


curred.  The  quantity  that  may  be  given 
without  danger  is  sometimes  surprising, 
but  the  character  of  the  malady  in  which 
it  is  exhibited  should  be  taken  into  ac- 
count. For  instance,  so  satisfactory 
has  it  generally  proved,  in  large  doses, 
in  the  treatment  of  hydrocephalus,  that 
many  of  the  older  practitioners  to-day 
deem  it  a  specific. 

Nervous  Diseases.  —  Although  no 
direct  action  is  produced  on  brain-tissue 
by  digitalis,  it  may  be  imagined  some 
alteration  in  cerebral  function  may  fol- 
low changes  induced  in  the  vascular 
system;  hence  the  apparent  benefit 
oftentimes  experienced  from  the  em- 
pirical employment  of  the  drug  in  vari- 
ous forms  of  mental  alienation  and  in 
epilepsy.  For  nearly  a  century  the 
remedy  has  been  considered  in  Germany 
as  an  almost  specific  in  mania. 

In  epilepsy,  though  it  has  produced 
no  cure,  it  is  evident  that  the  use  of 
digitalis  ought  not  to  be  too  hastily 
forsaken.  In  mania  it  is  often  ex- 
hibited with  good  efTect.  Barton  ("Cul- 
len's  Treatise  on  Mat.  Med.,"  vol.  ii,  '12). 
The  use  of  digitalis  should  be  limited 
to  those  cases  where  the  malady  is  de- 
pendent upon  disease  of  the  heart  and 
particularly  where  there  is  increased 
fullness  and  pulsation  of  carotids  and 
temporal  arteries.  Foville  (Waring's 
"Prac.  Therap.,"  '95). 

Careful  examination  of  literature  re- 
veals opinions  about  equally  balanced  as 
to  good  or  ill  effects  of  digitalis  in  epi- 
lepsy; it  may,  therefore,  be  concluded 
that  the  subject  demands  more  careful 
and  detailed  attention  than  has  hitherto 
been  given  it.  In  many  cases  detailed 
it  is  evident  that  the  dose  employed  was 
too  small  to  be  productive  of  benefit;  in 
many  more  the  drug,  at  best,  was  only 
palliative.  In  the  north  of  Ireland 
where  the  drug  still  obtains  a  reputation 
as  a  specific,  the  doses  employed  are 
very  large. 


Diseases  of  Kidneys. — In  the  treat- 
ment of  albuminuria  digitalis  has  found 
many  advocates;  but,  as  will  be  readily 
understood  on  recalling  its  pliysiological 
relations,  it  cannot  be  held  a  remedy  for 
what  is  at  best  but  a  mere  symptom,  ex- 
cept its  activity  is  directed  toward  the 
primary  lesion,  and  that  referable  in- 
disputably to  the  central  organ  of  circu- 
lation; and  even  here  it  should  be  em- 
ployed only  most  watchfully  and  cau- 
tiously. Where  the  kidneys  are  involved 
with  any  morbid  process  having  its  in- 
ception in  the  cardiac  apparatus,  indi- 
vidual susceptibility  and  idiosyncrasy 
are  likely  to  be  highly  developed.  In 
acute  stage  of  Bright's  disease  digitalis 
poultice  and  dry  cupping  often  afford 
relief;  and  the  infusion  may  also  be 
employed  in  Vs-ounce  doses,  repeated 
every  two  hours  for  twenty-four  hours, 
or  as  long  as  ursemic  symptoms  are 
urgent.  The  drug  should  be  promptly 
discontinued  once  the  urine  begins  to 
flow,  and  diuresis  continued  with  the  aid 
of  mild,  diluent  beverages.  In  passive 
renal  congestion,  too,  which  is  generally 
associated  with  cardiac  disease,  digitalis 
may  be  indicated. 

Digital  is  of  service  in  granular  de- 
generation of  kidney  by  increasing  the 
quantity  of  urine  passed  and  lessening 
the  amount  of  solids  voided.  It  is  also 
of  senice  in  relieving  the  tension  of 
renal  capillaries.  Webster  ("Dynamical 
Therap.,"  '93). 

Because  it  is  claimed  that  digitalis  is 
a  drug  which  increases  the  force  of  the 
heart  and  contracts  the  vessels  of  the 
peripliery — except  those  of  the  kidneys 
— it  is  employed  indiscriminately  as  an 
ideal  diuretic  in  Brighfs  disease,  not- 
withstanding the  contra-indications  ob- 
servable in  capillary  tension  and  cordy 
pulse.  Such  irrational  therapeutics  can 
result  in  naught  but  harm.  It  seems 
almost  foolhardy  to  use  it  in  chronic 
nephritis  accompanied  with  high  periph- 
eral   blood-pressure,    as    it    usually     is, 


480 


DIGITALIS.    THERAPEUTICS. 


unless  preceded  by  a  short  course  of 
nitroglycerin  to  relieve  the  peripheral 
tension.  English  (Med.  and  Surg.  Kep., 
Aug.  22,  '96). 

Decidedly  beneficial  in  chronic  form 
of  Bright's  disease,  where  there  is  car- 
diac dilatation.  In  early  stage  of  the 
malady,  accompanied  by  cardiac  hyper- 
trophy and  high  arterial  tension,  it  is 
doubtful  if  digitalis  is  indicated,  either 
alone  or  in  combination.  Butler  ("Text- 
book of  Mat.  Med.,  Therap.,  and 
Pharm.,"  "96). 

Ukinart  Calculi,  etc.  —  Digitalis, 
from  its  effect  primarily  upon  the  cir- 
culation, and  secondarily  upon  the  renal 
organs,  is  often  a  valuable  adjunct  to 
antilithic  remedies.  It  is  not  itself  in 
any  sense  a  solvent  of  gravel  or  calculi, 
nor  is  there  any  evidence  of  remarkable 
power  in  mitigating  pain  or  otherwise 
alleviating  the  symptoms  that  accom- 
pany maladies  of  this  class;  but  Barton 
nearly  a  century  since  noted  that  the 
drug,  in  many  instances,  in  a  most  re- 
markable manner  relieves  the  trouble- 
some dysuria  which  is  dependent  upon 
stone  or  gravel. 

Cardialgia.  —  Here,  though  often 
recommended  in  doses  from  10  to  20 
minims  three  or  four  times  daily,  little 
can  be  generally  expected,  though  by  its 
action  on  the  heart  it  may  alleviate  pain 
contingent  upon  some  cardiac  disorder. 

Dyspnoea;  Asthma. — In  the  treat- 
ment of  maladies  of  this  class,  too,  the 
drug  has  found  a  place,  but  in  uncom- 
plicated forms  it  is  inferior,  both  as  to 
safety  and  efficacy,  to  other  drugs. 
Where  these  are  connected  with  disease 
of  the  heart  or  functional  palpitation, 
relief  may  be  afforded,  and  when  accom- 
plished the  digitalis  should  be  with- 
drawn, since  now  cither  opium  or  hen- 
bane, or  both,  will  better  answer  the 
purpose.  In  spasmodic  asthma  it  is  oc- 
casionally serviceable,  and  it  was  very 
extensively  employed  in  the  latter  part 


of  the  last  and  beginning  of  this  cen- 
tury. 

Phthisis. — Fifty  years  ago  the  rem- 
edy— like  pretty  nearly  everything  else 
at  some  time  during  its  therapeutic  life 
— was  regarded  as  a  panacea  for  phthisis; 
it  was  even  declared  that  by  means  of 
fox-glove  it  was  as  possible  to  arrest  pul- 
monary inflammation  with  as  much  cer- 
tainty as  an  intermittent  could  be  by 
means  of  cinchona  or  cinchonal  deriva- 
tives. It  is  now,  however,  very  rationally 
rejected  as  a  cure,  and  merits  only  to  be 
regarded  as  one  of  the  many  means  oc- 
casionally useful  in  this  malady,  and 
which  may  sometimes  assist  more  im- 
portant measures.  In  hsemoptysis,  as  in 
other  hemorrhages,  it  is  sometimes  of 
great  service. 

Pneumonia.  —  In  pneumonia,  how- 
ever, digitalis  is  often  distinctively  of 
the  utmost  value,  particularly  in  main- 
taining the  heart's  action  where  there  is 
adynamia,  and  for  the  promotion  of  the 
excretion  of  waste  through  the  kidneys. 
Another  fact  not  generally  noted  is 
that  many  cases  of  pneumonia  result 
fatally,  not  from  the  pulmonary  con- 
gestion, but  from  urtemic  poisoning; 
this  fact  is  entirely  lost  sight  of  because 
the  attention  of  the  practitioner  is  gen- 
erally absorbed  by  the  primary  lesion. 
(Sajous.) 

Series  of  eight  hundred  and  twenty-five 
cases  of  pneumonia  treated  with  infusion 
of  digitalis: — 

B  Digitalis-leaves,  GO  to  00  grains. 
Water,  52  drachms. 
Simple  syrup,  12  drachma. — M. 
A  tablespoonful  every  half-hour.    This 
continued  for  two  or  three  days  aborts 
the  disease  and  reduces  the  mortality  to 
2.00  per  cent.     Petrosco   (Trans.  XI  In- 
ternat.  Med.  Cong.,  '94). 

[lluchard  states  that  Roumanian  digi- 
talis may  possess  properties  varying 
greatly  from  that  of  other  countries. 
Ed.] 


DIGITALIS.    THERAPEUTICS. 


481 


The  effect  on  the  pulse  and  tempera- 
ture is  slight,  and,  in  view  of  the  danger- 
ous nature  of  the  remedy,  it  is  not  worth 
the  risk.  Lowenthal  (Centralb.  f.  d. 
Gesara.  Therap.,  '94). 

Tlie  remedy  imr  excellence.  Recoveries 
will  and  do  occur  in  greater  numbers 
when  treated  by  large  and  persistent 
doses  of  digitalis.  Paulison  (Med.  Age, 
Sept.  10,  '94). 

Seventy-four  cases  of  croupous  and 
thirty-four  of  lobar  pneumonia  treated 
with  large  doses  of  digitalis  most  sat- 
isfactorily. Only  one  death:  that  from 
lobar  pneumonia.  Fickl  (Wiener  med. 
Woch.;   Med.  Age,  Oct.   10,  '94). 

Twenty-one  adults  and  thirteen  chil- 
dren suffering  from  cataiThal  pneumonia 
treated  with  large  doses  of  strong  in- 
fusion of  digitalis.  The  adults  bore  the 
doses  well,  but  the  children  frequently 
exhibited  evidence  of  gastro-intestinal 
disturbance.  Favorable  results  in 
eighteen  cases.  Ordinary  or  small  doses 
of  digitalis  have  no  influence  upon  the 
pulse  or  upon  the  progress  of  acute 
pulmonary  disease.  Strong  infusions 
are  harmless,  and  have  very  favorable 
influence  upon  the  process  of  the  disease, 
and  may  even  cut  it  short  if  adminis- 
tered at  the  onset.  Contra-indicated  in 
children  of  one  year  and  under,  and  in 
old  people.  Bloch  (Wratsch,  Nos.  1.5,  IG, 
'94). 

Often  of  great  value  in  various  acute 
diseases,  such  as  adynamic  pneumonia 
and  adynamic  fevers,  by  maintaining  the 
heart's  action.  It  can  have  no  effect 
upon  the  diseases  themselves,  but  may 
help  most  opportunely  to  sustain  the 
heart  during  a  crisis  or  a  period  of  strain 
upon  it.  H.  C.  Wood  ("Princ.  and  Prac. 
of  Therap.,"  '94). 

In  congestion  of  the  lungs  with  high 
fever  it  is  often  a  valuable  remedy  in 
relieving  venous  stasis.  In  the  second 
stage  of  pneumonia  it  is  of  the  greatest 
importance,  being  of  use  here  to  stimu- 
late the  contractile  force  of  the  cardiac 
muscle  when  the  intraventricular  press- 
ure becomes  stronger  than  the  unaided 
muscle  can  resist,  and  dil.itation  is  im- 
minent, if  not  already  begun.  The  main 
indication  for  the  drug  is   the  increase 


in  intensity  of  the  second  pulmonic 
sound.  Butler  ("Text-book  of  Mat. 
Med.,  Therap.,  and  Pharm.,"  '9G). 

If  the  patient  is  strong,  under  40,  with 
no  concomitant  organic  disease,  prefer- 
ence must  be  given  to  the  treatment  by 
baths;  under  opposite  conditions,  espe- 
cially when  the  heart  is  feeble,  digitalis 
should  be  given  in  doses  of  45  and  85 
grains  of  the  powdered  leaves  a  day,  ex- 
hibiting it  every  two  hours  infused  in 
water  with  the  addition  of  rum  and 
syrup  of  orange-peel.  Slight  vomiting 
and  vertigo  are  not  contra-indications, 
but  the  treatment  must  be  continued 
till  the  pulse  becomes  abnormally  slow 
or  irregular.  It  is  doubtful  whether  the 
enormous  doses  given  by  Petrescu  are 
free  from  risk,  and  whether  the  artificial 
lowering  of  temperature  by  them  is  of 
real  value.  The  maximum  dose  should 
not  exceed  45  grains  daily  of  the 
powdered  leaves.  Earth  (La  Sem.  Mfd., 
July  22,  '96). 

Pleurisy. — That  digitalis  may  be  a 
remedy  of  value  in  pleurisy  where  there 
is  effusion,  goes  without  saying,  but 
some  believe  it  is  indicated  at  even  an 
earlier  period,  on  the  theory  that  it 
combats  hyperremia.  This,  after  all,  is 
only  an  indorsement  of  the  practices  of 
Sir  Thomas  Watson,  Aitken,  and  Xie- 
meyer,  who  all  held  that  the  drug  was 
especially  adapted  to  the  pre-exudative 
stage;  and,  even  a  quarter  of  a  century 
back,  the  view  that  the  drug  is  anti- 
phlogistic and  adenagic  had  by  no  means 
become  obsolete. 

ExornTHALMic  Goitre.  —  Disritalis 
has  also  been  employed  in  exophthalmic 
goitre  occasionally  with  considerable  suc- 
cess. 

Cases  of  exophthalmic  goitre  in  young 
subjects,  purely  functional  in  character, 
have  been  cured  by  digitalein;  and  the 
cardiac  irregularities  and  dilatation  of 
the  cervical  vessels  ameliorated  even  in 
incurable  oases.  Cawasjce  ("Prac.  Vade 
Mec.,"  Bombay,  '91). 

In  exophthalmic  goitre  it  sometimes 
quiets  the  heart  and  lessens  the  pulse- 


4S2 


DIGITALIS.    THERAPEUTICS. 


rate.  Stevens  ("Manual  of  Therap.," 
•94). 

Digitalis  occasionally  proves  efficient 
as  a  heart-tonic  In  exophthalmic  goitre. 
Biddle   ("JJat.  Med.  and  Therap.,"  '95). 

Patients  with  Graves's  disease  may 
improve  under  a  long  course  of  the  drug, 
but  generally  this  treatment  fails.  Hale 
White,  Lond.  ("Mat.  .  Med.,  Pharm., 
and  Therap.,"  '95). 

Alcoholisii  and  Deliriuii  Tke- 
MEXS. — Enormous  doses  of  digitalis  are 
often  tolerated  by  alcoholics,  and  espe- 
cially those  suffering  with  delirium  tre- 
mens, probably  "because  the  heart  has 
by  long  habit  become  very  much  be- 
numbed to  the  use  of  stimulants." 

Digitalis  is  wonderfully  effective,  par- 
ticularly where  there  is  low  arterial 
pressure.  Is  undoubtedly  less  serviceable 
in  delirium  tremens  characterized  by 
high  arterial  tension.  Butler  ("Text- 
book of  Mat.  Med.,  Therap.,  and 
Pharm.,"  '96). 

Seventy  cases  were  treated  by  the  late 
Mt.  Jones,  of  Jersey,  without  the  pro- 
duction of  any  alarming  symptoms;  but 
other  observers  were  not  so  fortunate, 
and  in  two  instances  the  patients  fell 
back  dead,  although  up  to  that  moment 
there  had  been  nothing  to  indicate 
serious  danger.  It  must  be  remembered 
that,  if  a  patient  dies  suddenly  when 
taking  digitalis,  the  death  is  always  at- 
tributed to  the  treatment;  whereas  it 
any  other  drug  were  given  the  result 
would  probably  be  attributed  to  the 
disease.  Murrell  ("Manual  of  Mat.  Med. 
and  Therap.,"  '90). 

The  following  conclusions  appear  to 
be  established:  That  digitalis  may  be 
given  in  large  doses  in  delirium  tremens 
witliout  danger.  That  it  very  often  does 
good,  producing  speedily,  in  most  cases, 
refreshing,  quiet  sleep,  and  even  when  it 
fails  it  will  generally  calm  undue  ex- 
citement. Tliat  some  cases  appear  to  bo 
uninfluenced  by  the  dnig,  tliough  there 
yet  remains  to  be  ascertained  the  forms 
of  the  disease  that  are  most  amenable 
thereto.  Under  this  treatment  some 
severe  asthenic  cases,  in  which,  owing  to 
the    great    prostration    present,    death   ' 


seemed  imminent,  have  rallied  astonish- 
ingly, and  ultimately  recovered;  the 
evidence  of  this  is  too  strong  to  be  dis- 
puted. Under  the  influence  of  digitalis 
the  weak,  rapid,  and  fluttering  pulse  has 
grown  steady  and  strong,  the  skin  has 
become  comfortably  moist  and  warm, 
and,  simultaneous!}'  with  the  improve- 
ment in  the  circulation  and  state  of  the 
skin,  the  general  condition  of  the  patient 
has  improved.  On  the  other  hand, 
personal  experience  in  many  instances 
has  evidenced  that  sthenic  forms  of  the 
disease  are  also  amenable  to  the  drug. 
Ringer  and  Sainsbury  ("Hand-book  of 
Therap.,"  '97). 

As  AN  Anapheodisiac. — It  has  been 
remarked  that  the  drug  is  held  to  be 
anaphrodisiac;  but  it  is  likewise  ac- 
credited with  aphrodisiac  properties.  If 
the  supposition  is  true  that  digitalis  has 
a  direct  affinity  for  the  genital  plexus,  it 
may  act  either  way  according  to  dose  and 
method  of  administration;  it  may  also, 
in  the  same  way,  render  the  tissues 
involved  either  anaemic  or  hyperaemic. 
Hence  it  has  been  used  in  spermator- 
rhoea and  gonorrhosa,  for  its  effect  on 
the  minute  blood-vessels  of  the  tissues 
and  its  supposed  anaphrodisiac  proper- 
ties. 

It  is  a  serviceable  anaphrodisiac  in 
spermatorrhoea,  in  conjunction  with  cold 
bathing  of  genitals.  Foster  ("Prao. 
Therap.,"  vol.  i,  '90). 

Few  remedies  arc  of  more  avail  in 
arresting  spermatorrhoea  than  digitalis 
in  1-drachm  or  2-drachm  doses  of  the 
infusion,  twice  or  thrice  daily.  Ringer 
and  Sainsbury  ("Hand-book  of  Therap.," 
'97). 

Febrile  Maladies.  —  Every  few 
years  there  appears  to  be  an  attempt  to 
rehabilitate  digitalis  as  an  antithermic 
and  antipyretic,  and  a  wonderful  amount 
of  evidence  favorable  thereto  is  elab- 
orated. The  general  application  of  the 
drug  in  this  direction  has  been  attended 
with  many  fatalities,  and  many  more 
have   occurred   that   have  never  found 


DILATATION  OF  THE  HEART.     VARIETIES.     SYMPTOMS. 


483 


record,  owing  to  the  ignorance  of  tlie 
prescriber  and  friends  of  the  patient. 
The  writer  saw,  during  one  summer., 
three  fatalities  that  could  be  traced 
directly  to  the  maladministration  of 
digitalis  given  as  an  antipyretic  in  mild 
cases  of  intermittent  and  remittent 
fever.  In  typhus  and  typhoid  the  agent 
has  been  most  lauded,  but  all  the  evi- 
dence adduced  in  its  favor  will  not  ex- 
cuse the  practitioner  who  employs  em- 
pirically only. 

Hernia. — The  writers  of  the  early 
part  of  the  century  were  wont  to  recom- 
mend the  use  of  this  drug  in  very  large 
doses  for  the  reduction  of  incarcerated 
hernia.  Thirty  years  ago  appeared  in 
the  Lancet,  London,  a  statement  that  if 
suppuration  of  a  gland  have  begun,  digi- 
talis would  prevent  the  formation  of  ab- 
scess. This  is  undoubtedly  true  in  many 
instances,  owing  to  promotion  of  in- 
creased absorption  and  elimination. 
G.  Aechie  Stockwell, 

New  York. 

DILATATION  OF  THE  HEAET. 

Definition. — Increase  in  the  size  of  the 
lieart,  due  to  enlargement  of  one  or  more 
of  its  cavities.  Clinically,  "dilatation"  is 
applied  to  an  enlarged,  but  failing,  heart 
displaying  the  phenomena  of  "ruptured 
•compensation." 

Varieties. — "Simple"  dilatation  is  the 
term  used  to  denote  that  condition  in 
which  the  walls  of  the  heart  remain  of 
comparatively  normal  thickness.  Inas- 
much, however,  as  the  cavities,  and  con- 
sequently their  walls,  are  more  extensive 
than  normal,  simple  dilatation  is  asso- 
ciated with  a  certain  amount  of  hyper- 
trophy. Dilatation  is  'liypertrophic" 
when  the  heart-walls  are  thicker  than 
normal.  Another  name  is  "active"  dila- 
tation; and  viewed  from  the  opposite 
fitand-point  it  becomes  "eccentric  hyper- 


trophy." In  "atrophic,"  or  "passive," 
dilatation  the  walls  are  thinner  than 
normal. 

Most  cases  of  dilatation  are  essentially 
chronic  in  their  development  and  pro- 
gress.   Some,  however,  are  acute. 

Symptoms. — Usually  the  earliest  indi- 
cation to  the  patient  of  his  trouble  is 
shortness  of  breath.  This  at  first  is  ap- 
parent only  upon  exertion,  but  in  well- 
developed  cases  it  becomes  a  source  of 
great  suffering.  Hardly  more  than  one 
word  can  be  uttered  without  a  pause  for 
breath;  and  sleep,  if  obtained  at  all,  is 
possible  only  in  the  vertical  position 
(orthopncea).  The  ordinary  automatic 
respiration  has  sometimes  to  be  supple- 
mented by  voluntary  efforts;  so  that 
when  sleep  does  come  the  dyspnoea  be- 
comes aggravated  and  soon  wakes  the 
patient. 

Another  early  symptom  is  palpitation 
with  a  sense  of  discomfort  or  oppression 
in  the  cardiac  region.  It  is  singular  that 
the  powerful  heave  of  an  hypertropliied 
heart  does  not  seem  to  obtrude  itself 
upon  the  consciousness  of  the  patient  so 
much  as  the  feeble  flutter  of  dilatation. 
There  may  also  be  a  cough,  with  white, 
frothy,  serous  expectoration.  The  poor 
circulation  in  the  brain  is  evidenced  by 
more  or  less  mental  slowness  and  easy 
fatigue,  with  impaired  memory,  despond- 
ency, ill-temper,  and  attacks  of  faintness. 
In  the  digestive  tract  the  passive  conges- 
tion of  the  stomach  is  evidenced  by  fer- 
mentation, heaviness,  nausea,  and  even 
vomiting.  The  bowels  are  usually  slug- 
gish, and  the  urine  is  scanty  and  high- 
colored,  with  a  deposit  of  urates. 

In  mild  degrees  of  dilatation  the  com- 
plexion is  pale,  in  more  advanced  cases 
dusky  or  cyanotic  with  blue  lips  and 
finger-nails.  The  extremities  are  apt  to 
be  cold  to  the  touch,  and  the  sluggish- 
ness of  the  capillary  circulation  is  illus- 


484 


DILATATION  OF  THE  HEART.    SYMPTOMS. 


trated  by  the  slow  return  of  color  to  any 
point  of  the  surface  after  firm  pressiire: 
the  shape  of  the  examiner's  hand  is,  as  it 
were,  stenciled  upon  the  cyanotic  sur- 
face. The  labored  breathing  is  noticed 
even  while  the  patient  is  at  rest,  but 
becomes  striking  upon  the  least  exertion. 
CEdema  invades  first  the  ankles,  thence 
creeps  upward  to  the  thighs  and  pu- 
denda, and  finally  invades  even  the  face 
and  arms.  Ascites  and  hydrothorax  are 
often  present.  It  is  not  unusual  to  find 
a  considerable  amount  of  fluid  in  one 
side  of  the  chest,  while  the  other  pre- 
sents merely  the  signs  of  oedema.  The 
eyes  are  somewhat  prominent  and  glassy. 
Frequently  the  liver  is  much  enlarged, 
reaching  even  to  the  level  of  the  navel. 
This  change  in  its  size  may  be  more  or 
less  obscured  by  the  ascites  present,  but 
in  that  case  can  often  be  demonstrated 
by  a  quick,  though  gentle,  pressure  of  the 
fingers  inward  (ballottement).  In  some 
cases  the  spleen  is  also  found  to  be  en- 
larged. 

Cardiac  dilatation,  to  a  moderate  ex- 
tent, is  far  from  uncommon  in  early  life; 
indeed,  in  childhood  the  heart  may  be 
said  to  dilate  with  especial  ease.  The 
dilatation  may  be  found  out  apart  from 
any  valvular  affection;  it  is  due  to 
blood-pressure  in  a  flabby,  ill-nourished, 
or  degenerated  heart,  and  may  occur 
without  there  being  any  resistance  to 
the  passage  of  blood  from  the  heart. 
Acute  infections,  such  as  broncho-pneu- 
monia, diphtheria,  and  acute  rheuma- 
tism are  particularly  liable  to  cause  this. 
In  any  such  ca.se  of  acute  disease  where 
the  dilatation  is  rapid,  a  recumbent  posi- 
tion should  be  enforced,  and  on  no  pre- 
tense should  the  patient  be  allowed  to 
lift  even  his  head  from  the  pillow.  The 
diet  should  be  regulated  so  that  those 
foods  that  tend  to  ferment  and  fill  the 
stomach  with  wind  should  be  forbidden; 
baked  apples,  grapes,  oranges,  and  acid 
fruits  arc  to  be  avoided.  The  patient 
Bhould  be  fed  with  milk,  custards,  strong 
soups,  yelk  of  egg,  and   rusk.     In  the 


matter  of  drugs,  if  the  case  be  a  rheu- 
matic one,  and  sodium  salicylate  being 
taken,  it  is  well  to  combine  with  it  5 
to  10  grains  of  iron  animonio-eitrate. 
Strychnine  is  of  great  avlue,  and  iron 
perchloride  with  solution  of  strychnine, 
given  in  full  doses  well  diluted  with 
aerated  water,  is  recommended.  Eustace 
Smith  (Practitioner;  Amer.  Jour.  Med. 
Sci.,  June,   1902). 

The  pulse  is  of  great  importance  both 
in  regard  to  diagnosis  and  prognosis.  It 
is  apt  to  be  frequent,  ill-sustained,  and 
irregular  in  both  force  and  rhythm.  The 
number  of  radial  pulsations  may  be  con- 
siderably less  than  the  number  of  heart- 
beats as  coimted  with  the  stethoscope. 
The  pulse-wave  is  apt  to  be  small,  but  in 
cases  where  previous  high  tension,  as  in 
arteriosclerosis,  has  dilated  the  periph- 
eral arteries,  the  wave  may  be  of  con- 
siderable volume.  Any  approach  to  ten- 
sion in  the  arteries  is  of  favorable  import 

The  phenomenon  known  as  bigeminal 
pulse  is  quite  frequent  in  cases  of  dilata- 
tion. Often  the  second  and  weaker  of 
these  twin  cardiac  impulses  fails  to  reach 
the  radius  in  perceptible  strength.  In- 
spection of  the  cardiac  region  shows  no 
such  bulging  as  may  be  present  in  cases 
of  hypertrophy,  except  when  the  pre- 
cedent hypertrophy  has  left  its  traces 
behind  it.  It  may  be  difficult  to  locate 
the  apex-beat  by  the  eye,  or  the  impulse 
may  seem  to  be  diffuse  and  not  to  im- 
pinge upon  exactly  the  same  point  with 
every  beat. 

Over  other  portions  of  the  heart  than 
the  apex  the  intercostal  spaces  may  some- 
times be  seen  to  protrude  and  recede  with 
the  action  of  the  heart,  and  sometimes, 
an  extensive  wavy  motion  may  be  ob- 
served over  the  cardiac  area.  Wlien  the 
right  ventricle  is  dilated,  there  is  more 
than  a  usual  amount  of  impulse  in  the 
epigastrium  below  and  to  the  right  of 
the  xiphoid  cartilage. 


DILATATION  OF  THE  HEAliT.     DIAGNOSIS. 


485 


Upon  palpation  the  heart-beat  is  found 
not  to  be  of  a  strong  and  heaving  char- 
acter, but  feeble  and  resembling  a  quick 
tapping  or  slapping  of  the  chest,  some- 
times with  more  or  less  of  a  tremulous 
sensation  imparted  to  the  hand.  Even 
when  the  eye  has  detected  the  apex-beat, 
the  hand  may  not  be  able  to  distinguish 
it.  The  most  satisfactory  mode  of  prac- 
ticing palpation  is  by  resting  the  whole 
hand,  as  lightly  as  possible,  over  the 
prfficordium,  and  then  testing  the  im- 
pressions thus  received  by  firmer  pressure 
and  by  digital  touch. 

Percussion  shows  an  increase  in  the 
area  of  cardiac  dullness  varying  some- 
what according  to  the  portion  or  portions 
of  the  heart  mainly  dilated.  Increase  in 
the  size  of  the  right  ventricle  makes  the 
heart  broader  than  normal,  but  not  much 
longer.  The  right  limit  of  dullness  may, 
in  such  a  case,  reach  or  even  extend  be- 
yond the  right  nipple.  Enlargement  of 
the  right  auricle  is  associated  with  in- 
crease of  dullness  at  the  right  edge  of  the 
sternum,  corresponding  to  the  second 
and  third  intercostal  spaces.  The  dilated 
left  ventricle  presents  an  area  of  cardiac 
dullness  not  much  wider  toward  the  right 
than  normal,  but  extending  do\\'nward 
to  the  seventh  or  eighth  intercostal  space, 
and  perhaps  an  inch  or  two  to  the  left  of 
the  normal  position  of  the  apex. 

By  means  of  auscultation  we  maj',  in 
the  first  place,  be  able  more  exactly  to 
locate  the  position  of  the  apex-beat  than 
by  either  inspection  or  palpation,  assum- 
ing that  it  corresponds  to  that  point 
where  the  first  sound  of  the  heart  is  loud- 
est. The  first  sound  of  the  heart  in  cases 
of  dilatation  may  be  louder  than  normal, 
but  it  is  devoid  of  muscular  quality,  be- 
ing short  and  valvular;  that  is,  closely 
resembling  the  normal  second  sound  of 
the  heart.  It  is  heard  with  more  dis- 
tinctness in  the  aortic  area  than  is  the 


first  sound  of  the  hypertrophied  heart. 
Frequently  there  is  also  heard  a  systolic 
murmur  at  the  apex,  due  to  regurgita- 
tion through  the  mitral  valve  or  tricus- 
pid, because  the  auriculo-ventricular 
opening  is  dilated  as  well  as  the  ven- 
tricle, and  consequently  has  become  too 
large  for  the  valve,  even  though  normal, 
to  close  it  efficiently  (relative  insuf- 
ficiency). The  second  sounds  at  the  base 
of  the  heart  are  of  variable  character  in 
diff'erent  cases.  If  they  are  tolerably 
sharp  and  distinct  they  are  somewhat 
reassuring,  as  indicating  that  the  ven- 
tricles still  possess  muscular  power. 
Another  important  point  (W.  II.  and  J. 
F.  H.  Broadbent)  is  the  length  of  the 
pause  between  the  first  and  second 
sounds  of  the  heart  as  compared  with  the 
pause  separating  one  cardiac  cycle  from 
another.  If  the  first  and  second  sounds 
are  separated  by  a  shorter  interval  than 
in  health,  we  must  infer  that  the  dilated 
ventricles  are  able  to  make  only  an  in- 
effective effort  at  systole,  while,  if  there 
is  a  longer  pause  between  the  first  and 
second  sounds  of  the  heart,  it  is  evident 
that  the  cardiac  muscle  still  possesses 
sufficient  vigor  to  make  a  prolonged  ef- 
fort to  overcome  the  obstacles  which  it 
meets  in  propelling  the  blood-current. 

'Wlien  tricuspid  regurgitation  exists, 
the  veins  in  the  neck  are  dark  and  turgid. 
Their  valves  show  like  knots.  Often  act- 
ual pulsation  in  them  may  be  demon- 
strated, especially  if  the  patient  takes  a 
horizontal  position.  Pressure  upon  the 
congested  liver  magnifies  the  engorge- 
ment of  the  jugulars. 

Diagnosis.  —  From  pure  hypertrophy 
dilatation  can  be  clearly  distinguished  by 
the  general  aspect  of  the  patient,  and  the 
evidences  of  imperfect  and  failing  circu- 
lation already  detailed.  In  both  condi- 
tions the  area  of  cardiac  dullness  is  in- 
creased, but  in  dilatation  we  do  not  ob- 


486 


DILATATION  OF  THE  HEART.    DIAGNOSIS. 


serve  the  strong  heaving  impulse  of  hy- 
pertrophy. In  general,  it  may  be  said 
that  the  two  are  opposites.  Hypertrophy 
is  an  exaggeration  of  the  normal  state, 
while  dilatation  is  a  condition  of  weak- 
ness and  failure. 

The  first  sound  of  the  hypertrophied 
heart  at  the  apex  may  not  be  so  loud  or 
distinct  as  in  dilatation,  being  low  and 
muffled,  and,  as  already  stated,  it  may 
be  inaudible  at  the  base;  but  there  is 
present  in  it  a  muscular  qualitj',  dis- 
tinguishable in  a  less  degree  over  the 
apex  of  a  normal  heart,  and  not  heard  in 
cases  of  dilatation. 

The  hypertrophied  heart  must  at  last, 
however,  enter  into  the  state  of  dilata- 
tion,— unless  its  owner  is  the  victim  of 
intercurrent  disease, — and  the  important 
practical  question  for  diagnosis  in  most 
cases  is  to  determine  what  degree  of  de- 
terioration has  already  been  reached  and 
how  much  longer  the  circulation  can  be 
maintained. 

Very  valuable  information  in  doubtful 
cases  with  regard  to  the  integrity  or 
otherwise  of  an  enlarged  heart  may  be 
obtained  by  causing  the  subject  under 
examination  to  make  somewhat  brisk 
muscular  exertion,  as  by  ascending  and 
descending  a  flight  of  stairs  or  by  hop- 
ping six  or  eight  yards  upon  one  foot. 
The  degenerated  heart  will  become 
unnaturally  accelerated  and  irregular, 
while  a  well-nourished  heart  will  act  even 
better  than  before. 

In  certain  cases  retraction  of  the  lung, 
83  in  chronic  phthisis,  leaves  a  compara- 
tively-normal heart  more  exposed  than 
in  health  and  might  occasion  a  mistake 
of  the  condition  for  one  of  dilatation. 
Factors  in  this  diagnosis  would  be  the 
history  of  the  case,  the  signs  of  pulmo- 
nary disease,  the  absence  of  venous  stasis 
in  other  parts  of  the  body,  and  the  fact 
that  the  border  of  the  lung  near  the 


heart  did  not  extend  inward  over  the 
cardiac  area  on  full  inspiration,  as  under 
normal  conditions  it  should. 

Mediastinal  tumors  may  cause  dullness 
in  the  cardiac  region,  but  they  are  apt 
to  extend  upward  and  to  the  right  or 
left  side;  and  the  heart-sounds  are  not 
audible  over  them  in  the  same  way  as 
over  the  dilated  heart.  In  thoracic  aneu- 
rism we  should  expect  to  find  a  heaving 
impulse  in  the  neighborhood  of  the  base 
of  the  heart,  with  other  positive  signs  of 
aneurism  and  without  the  changes  in  the 
cardiac  sounds  and  impulse  or  in  the 
general  circulation  seen  in  dilatation. 

A  more  difficult  question  is  to  dis- 
tinguish pericardial  effusion  from  cardiac 
dilatation.  In  certain  cases  this  seems 
to  the  writer  almost  impossible,  although 
in  the  great  majority  of  instances  a  defi- 
nite conclusion  can  undoubtedly  be 
reached.  In  pericarditis  we  are  more  apt 
to  have  a  history  of  an  acute  onset  with 
fever  and  pericardial  friction-sounds,  and 
perhaps,  also,  knowledge  of  a  nephritis 
or  tuberculosis  or  acute  pneumonia  as 
etiological  factors  in  the  production  of 
pericarditis. 

The  pericardial  effusions  give  an  area 
of  dullness  somewhat  more  pear-shaped 
than  that  seen  in  dilatation  of  the  heart, 
which  is,  more  or  less,  quadrilateral. 
Pericardial  effusion  also  raises  the  apex- 
beat  upward  and  outward  toward  the 
third  or  fourth  spaces  in  the  neighbor- 
hood of  the  left  nipple,  and  it  renders 
the  heart-sounds  less  distinctly  audible 
than  in  dilatation.  It  may  also  cause  a 
paradoxical  pulse.  Yet,  in  case  of  val- 
vular heart  disease  with  a  fresh  attack 
of  rheumatism,  a  recent  pcricarditic  fric- 
tion-sound, and  evident  failure  of  com- 
pensation, it  may  be  very  difficult  to 
determine  whether  the  increased  area  of 
dullness  on  the  right  side  of  the  sternum 


DILATATION  OF  THE  HEART.     ETIOLOGY. 


487 


is  referable  to  pericardial  effusion  or  to 
dilatation  of  the  right  ventricle. 

In  the  cases  already  spoken  of  there 
has  been  a  question  of  mistaking  the  en- 
larged area  of  dullness  in  the  cardiac 
region  due  to  other  causes  for  a  dilated 
heart.  There  is  a  contrary  danger  in 
cases  of  emphysema  that  a  dilated  heart 
may  not  be  recognized  because  of  un- 
natural pulmonary  resonance  encroach- 
ing upon  the  true  cardiac  area.  Here 
we  may  be  saved  from  error  by  the  his- 
tory of  chronic  bronchitis,  and  of  al- 
ready-established and  slowly-increasing 
dyspnoea,  as  well  as  by  the  characteristic 
pulmonary  signs. 

Etiology. — Increase  in  the  cavities  of 
the  heart  must  be  due  either  to  abnormal 
weakness  of  their  walls  or  excessive  labor 
in  the  propulsion  of  the  blood-current. 
Among  obstacles  to  the  circulation 
should  be  enumerated  valvular  disease, 
arteriosclerosis,  chronic  interstitial  ne- 
phritis, atheroma,  and  congenital  nar- 
rowness of  the  aorta.  Contrary  to  what 
might  be  presupposed,  thoracic  aneu- 
rism does  not  cause  change  in  the  heart- 
walls,  unless  associated  with  aortic  re- 
gurgitations. Pericardial  adhesions  may 
cause  dilatation  of  the  heart,  more  es- 
pecially when  the  outer  surface  of  the 
pericardium  is  fastened  to  the  chest-wall 
or  diaphragm. 

Exophthalmic  goitre  and  tachycardia 
cause  cardiac  dilatation,  as  may  also  ex- 
cesses in  tobacco  and  venery,  great  anxi- 
ety and  despondency,  loukn?mia,  and 
chlorosis. 

Causes  in  300  cases:  Avtcriosclerosia 
in  50  per  cent.;  chronic  nephritis  in 
13.4  per  cent.;  valvular  lesions  in  12.4 
per  cent.;  adhesions  in  the  pericardium 
in  7.0  per  cent.;  excessive  muscular 
work  in  3.8  per  cent.;  tumors  in  1.9 
ppr  cent.;  aneurisms  in  O.O.i  per  cent. 
Ladeur  (Jlontrcnl  Med.  Jour..  Jfay,  'O.'i). 
Principal  causes,  other  than  disease  of 
the    valves,    myocardium,    and    pericar- 


dium:     1.  Organic    changes    in    arterial 
system.    2.  Overfilling  of  circulation.    3. 
'  Foreign    substances    in    the    blood.     4. 

Causes  that  act  on  general  cardiac  nerv- 
ous  system.     Arteriosclerosis   the   most 
important  factor.    J.  Stewart  (Montreal 
j  Med.  Jour.,  Apr.,  '95). 

j  Acute    dilatation    of    the    heart    can 

I  occur  in  acute  rheumatism.    Four  eases 

I  in  which   no   valvular   lesion   could   be 

!  found.     The   lack   of   resistance   of   the 

myocardium    doubtless    permitted    the 
dilatation   to   occur.     Dilatation   is   di- 
!  visible  into  two  classes:    one  due  to  pri- 

mary atony  of  the  myocardium,  to  be 
treated  by  digitalis;    the  other  due  to 
secondary    atony    of    the    myocardium, 
!  following  vasoconstriction  and  arterial 

I  tension.    Huchard  (Jour,  des  Praticiens, 

Apr.  27,  1901). 
Habitual  severe  and  sustained  physical 
exertion  may  cause  cardiac  dilatation,  as 
seen  in  both  athletes  and  in  men  follow- 
ing laborious  occupations.    Sudden  dila- 
:  tation  may,  indeed,  ensue  upon  a  single 
violent  or  prolonged  muscular  effort.    In 
many  cases  of  this  sort  it  is  presumable 
!  that  the  myocardium  was  previously  in 
a  vulnerable  condition;    but  j'et  dilata- 
\  tion  may  occur  in  young  and  apparently 
healthy  men   after  mountain-climbing, 
and,  after  a  period  of  due  rest,  be  com- 
i  pletely  recovered  from.    In  other  cases, 
however,  especially  in  persons  with  less 
elasticity  of  constitution,  the  lesion  is  a 
permanent  one  and  progresses  to  a  fatal 
termination. 

In  ten  runners,  who  had  just  reached 
the  goal,  apex  seemed  to  have  deviated 
to  the  left  from  two  to  three  centime- 
ti'es.  In  one,  alTectcd  with  aortic  in- 
sufficiency, apex  lowered  and  notable  in- 
crease of  prtrcordini  dullness,  evidently 
connected  with  dilatation  of  right  cavi- 
ties. Among  all  the  men  arterial  press- 
tu-e  lowered.  Mechanism  seems  to  relate 
to  overtaxing,  general  fatigue,  and  to  se- 
creted toxic  products.  Teissier  (Le  Bull. 
Mfd.,  Dec.  19,  '94). 

Excessive  work  thrown  upon  normal 
right  ventricle  presents  fairly-distinctive 
symptom, — namely,  pain,  localized  in  the 


488 


DILATATION  OF  THE  HEART.    ETIOLOGY. 


region  of  the  second  and  third  left  costal 
cartilages;  usually  dull,  but  may  be 
acute;  sense  of  tightness  in  prsecordia. 
In  the  adolescent  type  of  dilatation  in- 
crease of  size  upward  and  to  the  left, 
giving  increased  area  of  relative  cardiac 
dullness  in  third,  second,  and  soiuetimes 
first  left  interspaces.  F.  Stacey  Wilson 
(Birmingham  Med.  Rev.;  Sept.,  "94). 

Cycling  tells  primarily  and  distinct- 
ively on  the  heart  and  circulation.  Ben- 
jamin Ward  Richardson  (Asclepiad, 
Third  Quarter,  '94-'95). 

Several  subjects  in  which  death  had 
occurred  from  heart-strain.  Marked  dila- 
tation of  coronary  veins  and  their  sub- 
epicardial branches.  Microscopically, 
dilatation  seen  to  extend  to  capillaries 
between  individual  muscle-bundles.  In- 
termuscular connective  tissue  granular 
and  cloudy.  Muscle-cells  showed  vacuo- 
lar degeneration.  Venous  congestion  and 
oedema  of  muscular  bundles  and  con- 
nective tissue.  Banti  (Centralb.  f.  allg. 
Path.  u.  patli.  Anat.,  B.  0,  Isios.  14,  15, 
'95). 

Segmentary  dissociation  of  the  myo- 
cardium in  a  fatal  case  of  strained  heart. 
Fibre  seemed  to  have  its  continuity 
broken  at  the  level  of  the  intercellular 
cement.  Ffilex  Ramond  (Le  Bull.  Med., 
Dec.  8,  '95). 

Pulse  after  violent  use  of  bicycle  in 
some  cases  reached  250;  aften  ten  hours' 
rest,  heart  still  accelerated:  a  sign  of 
beginning  insufficiency.  Mendelssohn 
(Med.  Press  and  Circular,  Jan.  15,  '9G). 

Study  of  the  lesser  degrees  of  cardiac 
weakness  and  dilatation.  After  fatigue 
the  heart  is  in  a  temporarily-relaxed 
condition,  similar  to  that  of  the  skeletal 
muscles  after  severe  exertion.  After 
wrestling  the  heart  may  be  temporarily 
dilated,  and,  as  the  pulse  indicates,  may 
contract  with  much  diminished  force. 
The  temporary  and  physiological  relaxed 
condition  of  the  organ  merges  by  inter- 
mediate dcgrccB  into  one  of  actual  dila- 
tation. Clinical  observations  indicating 
three  phases  of  patliological  relaxation 
of  the  heart;  — 

1.  A  premonitory  stage  characterized 
by  palpitation,  excitability  of  the  heart's 
action,  feeling  of  fatigue,  and  slight 
an.tiety.    Cases  of  this  kind  should  not 


be  regarded  as  merely  nervous.  As  etio- 
logical factors  the  following  are  men- 
tioned: Rapid  growth  at  puberty,  sex- 
ual excesses  and  masturbation,  physical 
and  mental  overwork,  mental  troubles, 
anaemia,  alcohol  and  nicotine,  fatty  in- 
filtration, previous  illnesses,  and  prema- 
ture old  age. 

2.  The  first  stage  of  actual  relaxation. 
This  is  divided  into  an  acute,  a  subacute, 
and  an  intermittent  form;  such  cases 
are  often  labeled  as  cardiac  neui-asthenia. 

3.  This  class  embraces  the  ordinary 
cases  of  actual  dilatation,  on  which  so 
much  has  been  written. 

The  early  stages  should  be  especially 
sought  for.  The  early  stages  of  cardiac 
dilatation  should  be  recognized,  just  as 
much  as  the  early  stages  of  pulmonary 
tuberculosis,  so  that  the  condition  may 
be  opposed  in  time.  Concordance  with 
Gerhardt  and  Friintzel  that  palpation  is 
more  important  than  percussion  for  esti- 
mating the  size  of  a  relaxed  heart.  One 
must  feel  in  the  intercostal  spaces  for 
the  left  ventricle  several  times  and  with 
the  patient  in  different  positions,  but 
especially  in  the  leaning-forward  posi- 
tion made  use  of  by  Gumprecht.  Wliit- 
wicki  and  Seeligmtiller  have  observed  a 
marked  difference  in  respiration  accord- 
ingly as  the  patient  lies  on  his  left  or 
his  right  side.  This  nuiy  bo  an  impor- 
tant symptom  of  dilatation  of  the  left 
ventricle.  In  one  case  was  noted  on  re- 
peated occasions  an  increase  of  twelve 
to  twenty  inspirations  in  the  minute 
when  the  patient  turned  from  his  right 
on  to  his  left  side.  L.  Fcilchcnfeld  (Brit. 
Med,  Jour.,  from  Berl.  kliu.  Woch.,  Feb. 
28,  '98). 

Case  in  a  bicyclist  who  had  been  in  the 
habit  of  taking  prolonged  rides  and  who 
had  accompliahed  several  century-runs. 
Marked  hypertrophy  and  dilatation  of 
the  heart,  the  latter  being  predominant. 
In  addition  a  systolic  murmur  was  audi- 
ble over  the  cardiac  area,  with  its  great- 
est intensity  at  the  apex.  The  patient 
readily  becomes  dyspnceic;  the  heart-beat 
is  ordinorily  38  to  40,  but  under  the 
induence  of  the  slightest  excitement  or 
exertion  it  increases  to  80  or  90.  J.  M. 
Taylor  (Phila.  Med,  Jour,,  Apr.  10,  '08). 

Active    dilatation    of    the    heart,    or 


DILATATION  OF  THE  HEART.    ETIOLOGY. 


489 


hyperdiastole,  is  frequently  met  with. 
Normally  the  heart-musele  dilates  act- 
ively within  certain  limits  in  order 
to  receive  tlie  incoming  blood-stream. 
Under  some  circumstances  this  hyper- 
diastole is  increased  beyond  the  normal. 
It  then  amounts  to  an  active  dilatation 
of  the  heart.  The  conditions  that  cause 
this  may  be  nervous,  or  alteration  in 
the  blood,  but  particularly  those  condi- 
tions in  which,  as  in  anaemia,  there  is  a 
demand  by  tlie  tissues  for  a  larger  quan- 
tity of  blood.  This  demand  cannot  be 
met  by  merely  increasing  the  number  of 
pulsations,  as  the  blood  would  not  re- 
main sufficiently  long  in  contact  with 
the  tissues.  It  can  be  met  only  by  in- 
creasing the  amount  of  blood  driven  out 
at  each  stroke.  Hyperdiastole  may  be 
seen  under  physiological  circumstances 
at  times,  as  in  normal  persons,  after 
climbing  mountains.  It  is  often  seen 
after  hot  baths,  during  digestion,  and, 
at  times,  during  pregnancy.  H.  Herz 
(Deutsche  med.  Woch.,  Feb.  22,  1900). 

Weakness  and  dilatation  of  the  heart 
due  to  chronic  changes  in  the  myocar- 
dium is  caused  by  various  types  of 
chronic  nutritional  diseases,  and  is  of 
frequent  occurrence  in  such  affections. 
Microscopical  changes  may  not  be  ap- 
parent, or  we  may  observe  interstitial 
myocarditis,  or  fatty,  granular,  or  pig- 
mentary degeneration.  We  cannot  ex- 
pect a  normal  and  naturally  acting 
heart  in  a  chi-onically  diseased  and  de- 
bilitated body.  Perfect  metabolism  and 
normal  innervation  are  essential  to  pre- 
serve the  heart  miiscle  in  its  normal 
histological  condition.  Dilat;vtion  is 
caused  by  overstrain  of  the  cardiac 
muscle,  and  the  amount  of  stress  which 
the  cardiac  muscle  can  stand  is  rela- 
tive, depending  entirely  upon  its  con- 
dition, this  depending  in  turn  upon  the 
general  body  condition.  Slight  grades 
of  dilatation  occur  in  all  the  severer 
types  of  antemia  and  are  conmion  in 
chronic  gastro-intestinal  disorders.  G. 
W.  McCaskcy  (Proc.  Amer.  Med.  As- 
soc. Amcr.  jNlcd..  May  10.  1!)03). 

Other  causes  are  acute  nephritis,  as 
after  scarlet  fever,  rheumatic  pericarditis 
and    myocarditis,    pneumonia,    and    ty- 


phoid fever.  Influenza  certainly  may 
precipitate  dilatation,  if  it  does  not  act- 
ually cause  it. 

Detective  development  of  thorax  im- 
portant in  the  etiology  of  pseudohyper- 
trophies  of  adolescence.  Thorax  elon- 
gated and  constricted;  heart  forced 
downward,  ape.x  sometimes  as  low  as 
fifth  intercostal  space.  Huchard  (La 
Semaine  Med.,  Nov.  3,  '94). 

Connection  between  kidney  disease  and 
cardiac  hypertrophy  attributed  to  pri- 
mary toxicity  of  the  blood.  De  Domini- 
cis  (Wiener  med.  Woch.,  Nov.  17  to  Dec. 
1,  '94). 

Role  ascribed  by  some  authorities  to 

ordinary  growth  in  production  of  organic 

cardiac  conditions,  notably  hypertrophy, 

cannot    be    demonstrated.      Potain    and 

Vaques  (La  Semaine  Med'.,  Sept.  25,  '95). 

High  tension  in  the  systemic  arteries, 

aortic  stenosis,  and  aortic  regurgitation 

cause  a  predominant  change  in  the  left 

ventricle  as  compared  with   the  other 

cavities. 

Results  of  examinations  of  139  vessels 
of  all  sizes.  In  smaller  arteries  thicken- 
ing affecting  both  muscular  and  fibrous 
coats.  Thickening  greater  in  small  ves- 
sels than  in  larger.  With  chronic  granu- 
lar kidney  hypertrophy  of  the  muscle 
and  of  the  fibrous  tissue  of  whole  arterial 
system  connected  with  left  side  of  the 
heart  and  of  muscles  of  the  heart.  W. 
Howship  Dickinson  (Lancet,  July  20, 
Aug.  3,  '95). 

In  certain  graye  states  of  cardiac  dila- 
tation, and  in  advanced  valvular  disease, 
the   blood-pressure   as   tested   by   Hill's 
instrument   may    be   enormou.sly    high: 
a  fact  accounted  for  by  admitting  that 
the  ventricle  is  called  upon  to  work  at 
its  highest  pressure.     Nicholson   (Brit. 
Med.  Jour.,  Apr.  13,  1901). 
In  aortic  regurgitation  the  dilatation 
is  beneficial  with  certain  limits.     Inas- 
much as  a  certain  portion  of  the  blood 
pressed  into  the  aorta  with  each  systole 
is  at  once  allowed  to  return  to  the  ven- 
tricle, the  total  amount  of  blood  pressed 
out  with  the  systole  must  be  greater  than 
in  health,  or  there  will  inevitably  be  a 


490 


DILATATION  OF  THE  HEART.     ETIOLOGY. 


diminution  in  the  normal  amount  in  the 
arterial  system.  In  its  final  development 
aortic  insufficiency  presents  dilatation  of 
all  the  cavities  of  the  heart.  In  case  of 
mitral  regurgitation  there  is  also  dilata- 
tion of  the  left  ventricle,  because  a  leak 
in  the  mitral  valve  during  s3'stole  over- 
distends  the  left  auricle,  and  during  dias- 
tole the  blood  rushes  into  the  left  ven- 
tricle imder  more  than  normal  tension, 
enlarging  its  cavity.  The  usual  and  chief 
effect  of  mitral  lesions,  ho'^ever,  is  en- 
largement of  the  right  side  of  the  heart: 
at  first  of  the  right  ventricle,  and,  when 
it  begins  to  fail,  also  of  the  right  auricle. 
The  right  auricle  seldom  undergoes 
much  hj'pertrophy;  any  increase  in  its 
size  is  apt  to  be  a  pure  dilatation. 

Hypertrophy  is  never  primary  in  a 
hard-working  heart,  whether  increased 
labor  be  due  to  resistance  from  within, 
from  without,  or  to  nervous  stimulation 
and  augmented  action.  Primary  dila- 
tation is  a  compensatory  element.  Re- 
sidual blood  dilates  the  cavities,  and 
diminishes  the  extent  to  which  each 
fibre  is  called  upon  to  contract.  J.  G. 
Adami  (Montreal  Med.  Jour.,  May,  '95). 

The  stress  of  initial  stenosis,  pulmo- 
nary stenosis,  and  chronic  pulmonary 
disease  falls  upon  the  right  side  of  the 
heart.  Predominant  dilatation  of  the 
right  ventricle  makes  the  heart  globular 
in  shape. 

Temporary  dilatation  of  the  heart  may 
occur  under  both  physiological  and 
pathological  conditions.  It  cannot  be 
explained  as  only  apparent  and  ascribed 
to  the  action  of  respiration,  for  ordinary 
respiration  docs  not  sensibly  modify  the 
area  of  the  cardiac  dullness,  and  may 
occur  four  or  five  times  in  a  minute. 
The  phenomenon  may  be  explained  by 
suddenly  increased  intracardiac  pressure 
or  by  diminished  tonicity  of  the  ventric- 
ular wall.  G.  SC-e  (La  Mfd.  Mod.,  June 
4,  '91). 

Reticulated  condition  of  the  myocar- 
dium obscn'cd  in  the  case  of  a  woman 
afflicted  with  mitral  obstruction  and  re- 


gurgitation, who  died,  at  the  age  of  40, 
after  eighteen  months  of  chronic  asys- 
tole. The  interstitial  spaces  of  the  myo- 
cardium were  found  to  be  dilated  with- 
out signs  of  an  inflammatory  process. 
The  authors  explanation  is  that  a 
chronic  interstitial  redema  had  stretched 
apart  the  nmscular  fibres,  and  that  the 
condition  was  a  result  of  venous  and 
lymphatic  stasis.  Maurice  Letulle  (Bull, 
d'e  la  Soc.  Anat.,  No.  25,  '93). 

Acute  dilatation  of  the  heart  occur- 
ring in  the  course  of  cancrura  oris.  The 
area  of  cardiac  dullness  had  rapidly  ex- 
tended, the  apex  was  beating  an  inch 
and  a  half  external  to  the  nipple,  and 
over  area  there  was  heard  for  the  first 
time  a  loud,  blowing,  systolic  murmur. 
The  principal  point  of  interest  in  the 
case  is  the  rapidity  with  which  the 
heart  dilated.  When  the  patient  came 
under  observation  it  was  noted  that  her 
heart  was  healthy  and  its  area  of  per- 
cussion normal.  In  the  course  of  the 
illness  the  apex  of  the  heart  could  be 
seen  getting  carried  farther  and  farther 
daily,  and  all  at  once  a  mitral  systolic 
murmur  developed,  and  the  pulse  be- 
came rapid  and  irregular.  The  heart 
dilated  owing  to  malnutrition  of  the 
mj'ocardium,  either  from  fever  or  from 
the  poisoned  blood,  and  the  mitral  sys- 
tolic murmur  that  developed  was  ady- 
namic rather  than  cndocarditic.  Thomas 
Oliver  (Edinburgh  Med.  Jour.,  Mar.,  '98). 

An  examination  of  the  minute  struct- 
ure of  the  myocardium  in  dilatation  may 
show  either  interstitial  myocarditis  or 
fatty  degeneration,  or  there  may  be  no 
change  in  the  heart-fibres  appreciable 
even  with  the  microscope.  In  certain  of 
these  cases  it  would  seem  probable  that 
the  nervous  ganglia  connected  with  tlie 
heart  may  be  at  fault.  In  marked  dilata- 
tion the  pectinate  muscles  themselves  are 
flattened  into  mere  tendinovis  cords. 

[The  accompanying  illustrations  are 
from  photographs  of  specimens  in  the 
Warren  IMuseum  in  the  Harvard  Med- 
ical School,  for  advice  and  assistance  in 
obtaining  which  T  am  indebted  to  the 
courtesy  of  Dr.  William  V.  Whitney, 
Curator.    Heuman  Vickery.] 


DILATATION  OF  THE  HEART.     ETIOLOGY. 


491 


^ 


Fig.  1. — Dilnteil  left  vciitrklc  with  a  cardiiic  aueurism  at  apex.     Case  of  chrouic  interstitiiU 
myocarditis  in  a  man  aged  S+. 


Fig.  2. — Excessive  dilatation,  witli  livpirir.'iiliv,  i.r  ilic  right  ventricle.  Valves  of  piiliuonary 
artery  united  to  form  a  smooth  tlbrous  diaphragm  wltira  small  opening  In  the  centre.  Left 
ventricle  laid  open,  not  enlarged.   Case  of  a  boy  aged  14.    Cyanosis,  dyspncea,  sudden  death. 


492 


DILATATION  OF  THE  HEART.     ETIOLOGY. 


\. 


Fig.  3. — View  of  right  ventricle  of  s.iine  lieait. 


Fig.  4.— Left  vciitrleic  ftiently  dllatod,  but  Its  walla  of  norimil  tlilclciiess.  Aorta  extromaly 
atlicromntoiiB  and  cnlargi-il.  Man  ngi'd  44.  Cardlne  eyniiilonis  of  pain,  dyspnooa  and 
pill [iltnt Ion  (Vir  ii-n  years.     IJcatli  In  n  Bulzure. 


DILATATION  OF  THE  HEART.    PROGNOSIS. 


493 


Prognosis. — It  will  be  seen  from  what 
has  gone  before  that  dilatation  of  the 
heart  is  a  condition  which  it  is  not 
proper  to  generalize  when  considering 
any  individual  case.  The  state  might 
be  said  to  bear  the  same  relation  to 
heart  conditions  that  jaundice  holds  to 
the  liver  and  digestive  tract.  Each  case 
should,  therefore,  be  carefully  consid- 
ered on  its  own  merits  or  demerits. 

The  most  acute  transitory  form  of 
dilatation  is  probably  that  which  occurs 
in  athletes  and  others  under  great  or 
long-continued  effort.  The  majority  of 
these  persons,  if  in  good  health  and 
well  trained,  seem  to  escape  permanent 
injury.  It  will  be  found,  however,  that 
a  certain  important  proportion  of  those 
who  engage  in  violent  and  desperate 
competitive  physical  exertions,  as  for  in- 
stance, a  long  boat-race,  suffer  for  years 
thereafter  from  discomfort  in  the  cardiac 
region,  with  some  tendency  to  irregu- 
larity of  the  pulse. 

Those  who  train  athletes  should  ap- 
preciate this  possibility.  The  first  de- 
gree of  dilatation  and  consequent  venous 
stasis  is  shown  by  pallor,  for  this  reason: 
as  the  left  ventricle  becomes  tired,  blood 
accumulates  in  the  right  side  of  the 
heart,  and  the  systemic  veins  in  more 
than  normal  amount,  yet  not  exceeding 
the  capacity  of  the  venous  system.  As 
a  consequence  of  this  increase  of  blood 
in  the  venous  channels,  there  is  less 
blood  than  normal  in  the  arteries,  caus- 
ing a  pallor  which  does  not  advance  to 
cyanosis  until  a  much  greater  amount 
of  blood  is  present  in  the  veins.  If, 
then,  a  person  engaged  in  vigorous  exer- 
cise changes  from  the  ordinarj-  pink 
flush  of  countenance  to  a  decided  pallor, 
the  limit  of  safe  exertion  has  been 
reached.  Cyanosis  conveys  a  still  more 
imperative  warning. 

With  regard  to  the  more  common  and 


usually  slowly-developing  forms  of  dila- 
tation, it  should  be  said  that  there  may 
be  many  degrees  of  the  disease  in  dif- 
ferent persons.  Here,  too,  sudden  prog- 
ress in  the  wrong  direction  may  occur, 
as  the  result  of  overstrain, — changing 
a  moderate  into  a  severe  case.  In  gen- 
eral, it  may  be  said  that  the  patient  does 
not  often  survive  a  well-marked  condi- 
tion of  cardiac  dilatation  for  more  than 
twelve  or  eighteen  months. 

The  factors  upon  which  we  should  lay 
weight  in  determining  the  reserve  power 


Fig.  5. — Dilated  loft  ventricle  showing  tiabeculie 
flattened  nnd  indistinct.  Mitral  valves  exten- 
sively destroyed  and  covered  with  large  vege- 
tations. 


of  a  dilated  heart  are  of  two  kinds:  ra- 
tional and  physical.  If  the  disease  has 
come  on  in  one  whose  habits  can  be 
greatly  changed  for  the  better,  with  re- 
gard either  to  overindulgence  in  alco- 
hol, tobacco,  the  pleasures  of  the  table, 
and  such  like,  or  sorrow,  anxiety,  over- 
work, and  long  hours  of  sustained  effort, 
then  the  chances  are  somewhat  more 
favorable  than  if  the  subject  has  led 
a  physiologically  blameless  life.  The 
judiciousness  or  unsuitableness  of  the 
treatment  heretofore  adopted  should  also 


494 


DILATATION  OF  THE  HEART.    TEEATMEKT. 


be  considered.  And  those  who  have 
previously  undergone  one  or  two  attacks 
of  cardiac  failure  are  to  be  regarded 
in  a  more  dangerous  condition  than  dur- 
ing their  previous  illnesses. 

Irregularity  in  the  pulse  is  not  neces- 
sarily of  evil  import,  but  a  great  fre- 
quency of  the  pulse-rate  is  discouraging. 
Of  course,  any  degree  of  vigor  in  the 
cardiac  impulse  is  a  welcome  discovery, 
as  is  also  a  sharp  and  decided  quality 
in  the  second  sounds  at  the  base  of  the 
heart.  The  case  may  be  considerably 
affected  in  its  course  by  our  ability  to 
obtain  for  the  patient  a  fair  degree  of 
sleep  and  maintain  a  sufficient  mitrition 
of  the  body. 

It  is  oftener  possible  to  produce  a  cer- 
tain degree  of  improvement  than  to 
maintain  it,  to  say  nothing  of  complet- 
ing the  recovery. 

A  fatal  termination  may  be  preceded 
by  attacks  of  syncope,  often  most  alarm- 
ing; but  death  is  more  apt  to  come  at 
the  end  of  a  comatose  condition  than 
with  extreme  suddenness.  Embolism 
and  thrombosis  may  also  prove  terminal 
factors. 

Prognosis  in  acute  cardiac  inflamma- 
tion of  a  severe  type  is  mucli  worse  in 
childhood  than  in  later  life.  There  are 
three  reasons  for  this:  (1)  the  frequency 
with  which  both  the  endocardium  and 
pericardium  are  involved,  (2)  the  great 
tendenoj'  to  acute  dilatation,  and  (3)  the 
liability  of  these  attacks  to  be  compli- 
cated with  pneumonia.  Holt  (Archives 
of  Pediatrics,  Dec,  '99). 

Treatment. — Absolute  rest  in  bed  is 
very  desirable  if  the  patient  is  able  to 
enjoy  it.  In  many  cases,  however,  the 
sufferer  cannot  assume  the  horizontal 
position,  but  is  obliged  to  sit  either 
propped  up  in  bed  or  in  a  chair  where 
he  may  bend  his  knees.  For  such  un- 
fortunates, sleep  is  often  best  obtained 
by  providing  them  with  a  shelf  or  rest 


in  front  of  them  at  about  the  level  of 
the  elbows,  on  which  they  may  lean, 
bending  forward.  There  are  special 
tables  made  with  a  leaf  reaching  over 
the  bed. 

In  primary  weakness  and  dilatation 
of  the  heart  which  develop  chiefly  in 
anaemic  and  scrofulous  children,  they 
should  he  taken  away  from  school  at 
once,  kept  absolutely  quiet  in  fresh  air 
(preferably  at  the  sea-side),  and  given 
the  best  possible  diet  suitable  for  their 
age  and  digestive  power.  Martins  (Con- 
gress of  Inter.  Med.,  Carlsbad,  Apr.  11 
to  14,  ■99). 

The  diet  is  of  nearly  equal  importance 
with  bodily  rest.  It  should  be  bland, 
easily  digested,  and  given  in  small 
amounts  at  intervals  of  two  or  tliree 
hours.  Some  cases  have  seemed  to  do 
well  on  a  purely-milk  diet,  particularly 
such  as  have  suffered  from  high  arterial 
tension.  In  most,  however,  a  vai'iety  of 
rather  concentrated,  but  simple,  viands 
is  preferable.  Thus  we  may  allow  eggs, 
fowl,  underdone  beef  or  mutton,  beef- 
juice,  and  gruels  made  with  one-half 
milk  and  one-half  water.  Alcohol  as  a 
beverage  or  long-continued  tonic  is  use- 
less and  harmful.  It  should  be  reserved 
for  emergencies,  imless,  indeed,  the  pa- 
tient has  become  so  accustomed  to  it 
(hat  a  small  amount  of  whisky  or  dry 
wine  is  almost  necessary  to  stimvilate  the 
appetite  and  digestion.  It  is  the  view 
of  some  that  habitual  alcoholic  stimula- 
tion is  more  desirable  in  old  age  than  in 
earlier  life;  but  the  writer's  experience 
has  satisfied  him  that,  in  the  condi- 
tion under  consideration,  great  caution 
should  always  be  used  in  regulating  the 
administration  of  alcohol. 

Constipation  and  flatulence  interfere 
with  abdominal  respiration  and  impede 
the  venous  circulation.  Laxatives  are 
consequently  of  great  value,  and  more 
especially    hydragogic    cathartics.     En- 


DILATATION  OF  THE  HEAliT.    TREATMENT. 


495 


largement  of  the  liver  increases  the  ad- 
visabilitj'  of  their  employment.  In  suit- 
able cases  the  relief  from  a  purge  is  al- 
most magical.  It  seems  to  produce  the 
same  mechanical  effect  that  venesection 
would  without  the  loss  of  strength  which 
the  latter  measure  involves.  The  fa- 
vorite drug  is  mercury,  either  in  the 
form  of  blue  mass  or  the  mild  chloride. 
This  may  be  followed  the  next  morning 
by  a  dose  of  sulphate  of  magnesium  or 
sodium  in  concentrated  solution.  It  is 
said  that  the  advantage  of  mercury  over 
other  ^cathartics  is  that  it  not  only  de- 
pletes the  veins,  but  dilates  the  capilla- 
ries, and  thus  lessens  the  obstruction 
which  the  weakened  heart  has  to  over- 
come. Another  efficient  and  not  very 
unpleasant  remedy  for  the  same  purpose 
is  composed  of  equal  parts  of  bitartrate 
of  potassium  and  compound  jalap  pow- 
der, of  which  the  dose  is  1  or  2  tea- 
spoonfuls.  By  far  the  best  cardiac  stim- 
ulant in  this  condition  is  digitalis.  It 
should  be  given  in  etlicient  doses.  If  the 
desired  effect  is  not  obtained  with  ordi- 
nary amounts,  the  remedy  should  be 
gradually  pressed  until  either  there  is 
improvement  or  nausea  interferes  with 
its  further  administration.  In  some  cases 
it  may  be  given  by  means  of  an  enema 
when  the  stomach  altogether  rejects  it. 
Its  well-known  cumulative  action  should 
be  remembered,  and  it  should  not  be 
longer  continued  if  nausea  begins  or  the 
amount  of  urine  diminishes.  In  fact, 
practically,  one  must  be  ready  to  sus- 
pend it  about  as  soon  as  it  produces  a 
marked  satisfactory  effect  (see  Digi- 
talis). As  substitutes  for  digitalis, 
tincture  of  strophanthus,  caffeine,  and 
sulphate  of  sparteine  may  be  employed, 
their  probable  efficacy  being  in  the  order 
named. 

rdlet:?  of  cactinn.  Vi.«  grain  each,  one 
being  given  everv  two  hours  during  the 


day;  especially  efTeetive  in  weak  and 
dilated  heart.  Kola  cordial  as  a  cardiac 
tonic.  Campbell  (Montreal  Med.  Jour., 
June,  '95). 

Sparteine  sulphate  successfully  used  in 
cases  of  passive  dilatation  of  the  heart, 
especially  without  marked  valvular  le- 
sion. It  is  often  necessary  to  perma- 
nently continue  the  drug,  but  no  increase 
of  dose  is  necessary.  The  dose  is  '/i 
to  1  grain  every  four  hours.  P.  M.  Chap- 
man (Birmingham  Med.  Rev.,  May,  '99). 

In  subacute  dilatation  of  neurotic  or 
antemic  young  people,  where  baths  and 
exercises  are  not  available,  nutrients 
like  malt,  iron,  quinine,  and  the  alka- 
loids of  nu.\  vomica  may  check  the  dila- 
tation and  restore  the  heart's  tone.  In 
general,  strychnine  or  brucine,  in  '/«■  to 
'Ao-grain  doses  are  good  nerve-tonics, 
but,  as  they  contract  both  heart  and 
arterioles,  are  undesirable  for  contin- 
uous use.  T.  E.  Satterthwaite  (iledical 
News,  Dec.  28,  1901). 

Strychnine  is  often  of  great  value  and 
may  be  combined  with  any  of  these  or 
given  independently.  Iron  is  useful  for 
its  beneficial  effect  upon  the  nutrition 
of  the  heart-wall.  Quinine  and  arsenic 
are  advised  in  certain  cases.  It  is  hardly 
safe  to  give  the  latter  to  subjects  in 
whom  fatty  degeneration  is  suspected. 
On  the  other  hand,  arsenic  sometimes  ap- 
pears particularly  efficient  in  cases  where 
there  is  cardiac  pain. 

Minor  forms  of  cardiac  dilatation 
found  in  anfcmic  girls  just  past  the  age 
of  puberty.  They  sutler  from  menor- 
rhagia,  constipation,  and  flatulence.  In 
these  cases  the  action  is,  as  a  rule,  rapid, 
and  the  first  sound  is  exaggerated  and 
seemingly  irritable.  Best  results  come 
from  strychnine  and  digitalis  in  moder- 
ate doses  for  a  week  or  two,  to  be  fol- 
lowed by  a  prolonged  course  of  iron. 
Beverly  Robinson  (Amer.  Jour.  Med.  Sci., 
Aug.,  1900). 

Massage  may  do  good  in  two  ways, 
both  by  promoting  general  nutrition  and 
by  assisting  in  the  propulsion  of  the 
blood.     The   Schott   method   of   treat- 


496 


DILATATION  OF  THE  HEART.    TREATMENT. 


ment  may  be  of  advantage  in  less-alarm- 
ing cases  where  there  yet  remains  some 
muscular  integrity  in  the  heart.  Oertel's 
method  of  treatment  is  suitable  in  so  far 
as  the  amount  of  liquid  ingested  may 
often  be  limited  to  advantage,  but  un- 
suitable with  regard  to  the  forced  mus- 
cular effort  he  advised.  ■  Climbing  is 
more  useful  for  obesity  with  fatty  over- 
growth of  the  heart  than  for  conditions 
of  cardiac  dilatation.  Accumulations  of 
fluid  in  the  abdominal  or  thoracic  cavi- 
ties should  be  withdrawn.  It  is  some- 
times surprising  how  much  benefit  will 
follow  the  removal  of  twelve  or  sixteen 
ounces  of  water  from  the  chest  or  a  few 
quarts  from  the  abdomen. 

In  well-marked  cyanosis  with  consid- 
erable enlargement  of  the  liver  half  a 
dozen  leeches  may  give  relief.  They 
may  be  applied  directly  over  the  liver 
and  the  subsequent  bleeding  should  be 
encouraged  by  warm,  wet  compresses. 

Blood-letting  is  a  very  important 
remedy  when  the  heart  is  dilated  and 
there  are  passive  congestions  and 
dropsy.  It  is  especially  valuable  in 
dilatation  of  the  right  heart  when  there 
is  still  considerable  tension.  Venesec- 
tion is  not  to  be  performed  in  the  very 
young  or  old.  Leeches  to  the  epigas- 
trium may  be  employed  when  venesec- 
tion would  be  too  great  a  shock.  The 
amount  of  blood  to  be  withdrawn  de- 
pends upon  the  plethora  of  the  patient 
and  the  eflect  noticed.  Allyn  (Univer- 
sity Medical  Magazine,  Dec,  '99). 

In  many  bad  eases  of  dilatation  of  the 
right  heart,  with  cyanosis  and  orthop- 
noea,  when  nothing  but  a  large  vene- 
section appears  to  hold  out  a  promise, 
one,  two,  or  three  doses  each  of  10  or 
12  grains  of  digitalis,  given  at  intervals 
of  three  or  five  hours,  will  contract  the 
heart  and  restore  pulmonary  and  gen- 
eral circulation;  on  the  other  hand,  in 
chronic  conditions  of  weak  heart,  of 
either  muscular  or  nervous  origin,  or  of 
iniiullicicnt  action  caused  by  pulmonary 
obKtruction,  —  as    in     chronic     broncho- 


pneumonia or  in  tuberculous  infiltra- 
tion,— small  doses  of  digitalis,  that  is, 
from  4  to  6  grains  daily,  or  its  equiv- 
alent, may  be  given  for  weeks  and 
months  and  even  years  without  any 
hesitation.  Such  doses  may  be  ordered 
while  the  patient  is  not  expected  to  be 
seen  for  weeks  or  months.  In  most  per- 
sonal cases  prescribed  either  from  four 
to  six  doses  daily  of  Squibb's  or  any 
other  good  fluid  extract  or  the  solid 
extract  of  the  "Pharmacopceia"  in  the 
shape  of  pills,  1 '/.  grains  (0.1  gramme) 
daUy,  usually  Vj  grain  (0.03  gramme) 
three  times  a  day,  almost  always  in 
pills,  rarely  by  itself,  often  in  combina- 
tion with  sparteine,  or  strychnine,  or 
arsenic  or  other  drugs,  as  the  case  may 
require.  Patients  who  take  digitalis  in 
this  way  do  not  show  a  cumulative  ef- 
fect, nor  are  they  getting  accustomed 
to  it  to  such  an  extent  as  to  lose  the 
benefit  of  its  action. 

The  indications  for  the  use  of  digitalis 
are  the  insufficiency  of  the  heart-muscle 
and  the  incompetency  of  the  mitral 
valve.  Chronic  myocarditis  is  no  con- 
tra-indication.  Large  doses  may  over- 
exert the  inflamed  muscle;  that  is  why 
digitalis  in  large  doses  is  very  badly 
borne  in  acute  myocarditis;  small  doses 
are  often  serviceable  when  the  flrst 
onset  is  passed.  Aortic  insufficiency  has 
been  declared  a  contraindication  to 
digitalis  by  some,  an  indication  by  oth- 
ers. It  is  certain  that  these  observers 
had  difl'crcnt  cases  to  deal  with.  Aortic 
insufficiency,  when  incipient  or  moderate, 
is  easily  compensated,  gives  no  uneasi- 
ness to  the  patient,  is  not  complained 
of,  and  is  seldom  observed  when  recent. 
This  is  the  time  when  such  doses  of 
digitalis  continued  a  long  time  prove  of 
permanent  service.  Only  those,  how- 
ever, can  be  thus  benefited  whose  cases 
are  recognized  early,  cither  accidentally 
or  through  careful  self-observation  by 
th<-  patient.  When,  however,  the  case 
is  old  and  compensation  greatly  dis- 
turbed, with  considerable  peripheral 
venous  obstruction,  even  digitalis  will 
not  sufflee  to  restore  the  equilibrium 
between  the  action  of  the  heart  and  the 
cnpillary  circulation  of  distant  organs. 
A.  .rucol.i  (Medical  News,  Jan.  11,  1902). 


DILATATION  OF  THE  HEART. 


DIPHTHERIA. 


497 


The  legs  in  some  instances  are  im- 
mensely distended  with  fluid.  BulliE 
are  apt  to  form,  which  burst  spontane- 
ously and  exude  dropsical  fluid.  Large 
amounts  of  water  may  sometimes  be 
drawn  from  the  lower  extremities 
through  Southey's  capillary  trocars  or 
by  means  of  longitudinal  scarifications. 
A  practical  objection  to  the  latter 
method  is  the  great  danger  of  erysipelas 
attacking  the  scarified  tissues.  Apart 
from  th»t,  the  constant  dripping  day  and 
night  torments  the  patient  and  soon 
causes  more  or  less  eczema  of  the  skin. 
But  the  relief  to  the  circulation  is,  in 
some  instances,  worth  even  the  immense 
amount  of  trouble  and  the  considerable 
risk  thus  entailed. 

For  the  attacks  of  syncope  to  which 
these  patients  are  liable,  the  subcutane- 
ous injection  of  digitalis,  nitroglycerin, 
ether,  alcohol,  or  strychnine  is  neces- 
sary. Marked  relief  and  apparently  val- 
uable stimulation  are  sometimes  ob- 
tained by  the  inhalation  of  oxygen-gas, 
which  has  once  or  twice  seemed  to  the 
writer  actually  life-saving  in  its  efficacy. 
In  such  cases,  however,  a  fatal  termina- 
tion is  merely  delayed,  not  absolutely 
prevented. 

Herman  Vickert, 

Boston. 

DILATATION    OF   THE    STOMACH. 

See  STOMAcn,  Disorders  of. 

DIPHTHERIA.— From  the  Greek: 
<)i^Oi'pa,  a  skin  or  membrane. 

Definition. — Diphtheria  is  an  acute 
infectious  and  contagious  disease  pro- 
duced by  the  presence  and  development 
of  the  Klebs-Loeffler  bacillus.  As  it 
occurs  in  man,  it  is  usually  characterized 
by  the  presence  of  false  membranes  upon 
the  surfaces  primarily  attacked,  espe- 
cially the  mucous  membranes  of  the 
nose,  pharynx,  larynx,  or  trachea.  There 


can  no  longer  be  any  question  of  the 
specific  relation  between  the  great  ma- 
jority of  cases  of  the  disease  known  since 
the  time  of  Bretonneau  as  diphtheria 
and  the  bacillus  with  which  Klebs  and 
Loeffler  have  identified  their  names. 
The  bacillus  is  regularly  obtained  in 
cultures  from  afFected  throats;  it  can 
readily  be  isolated;  and  when  pure  cult- 
ures are  injected  in  animals  they  repro- 
duce the  essential  features  of  the  disease 
met  with  in  man.  Welch  and  others, 
by  inoculating  the  mucous  membranes 
of  guinea-pigs,  have  even  succeeded  in 
producing  the  false  membranes  so  closely 
associated  with  the  disease  in  man.  All 
the  constitutional  effects  and  character- 
istic lesions,  except  the  formation  of 
membrane  of  diphtheria,  have  likewise 
been  produced  by  the  injection  in  ani- 
mals of  the  toxins  produced  by  the  spe- 
cific bacillus.  In  experimental  diph- 
theria, induced  either  by  the  injection 
of  cultures  of  the  Klebs-LoefBer  bacillus 
or  of  its  toxins,  the  most  striking  feature 
is  the  production  in  animals  of  the 
paralyses  due  to  nerve  and  muscular  de- 
generations, such  paralyses  reproducing 
most  exactly  tlie  phenomena  so  often 
observed  in  clinical  diphtheria.  This 
feature  of  the  experimental  process  has 
so  impressed  itself  upon  those  most  in- 
terested in  laboratory  researches  that 
some  propose  to  define  diphtheria  as  an 
acute  infectious  disease,  produced  by  the 
action  of  the  Klebs-Loeffler  bacillus,  and 
characterized  by  the  development  of 
nerve-degenerations. 

AVliile  this  teaching  may  be  most  in 
harmony  with  the  combined  evidence  of 
clinical  observation  and  laboratory  re- 
search, it  does  not  yet  seem  advisable  to 
so  far  depart  from  the  conceptions  of 
diphtheria  which  have  heretofore  ob- 
tained. The  appearance  of  false  mem- 
brane has  long  been  regarded  as  almost 


493 


DIPHTHERIA.     ^'AKIETIES. 


diagnostic;  it  still  belongs  to  the  great 
majority  of  cases,  and  can  readily  be 
appreciated,  while  the  nerve-degenera- 
tions, if  they  appear  at  all  in  clinical 
diphtheria,  are  met  with  only  in  the 
later  stages  of  the  disease,  long  after  the 
question  of  diagnosis  will  have  been  de- 
termined. 

Varieties. — The  classification  of  the 
acute  inflammations  affecting  nose, 
throat,  etc.,  has  not  yet  reached  a  satis- 
factory stage.  The  distinctions  based 
upon  the  presence  or  absence  of  pseudo- 
membranes  have  lost  their  significance. 

TTlaile  the  great  majority  of  pseudo- 
membranous inflammations  of  these 
parts  are  due  to  the  action  of  the  diph- 
theria bacillus,  a  considerable  number 
of  such  inflammations  are  produced  by 
the  action  of  other  bacteria,  especially 
the  streptococci  and  staphylococci.  On 
the  other  hand,  the  action  of  the  diph- 
theria bacillus  is  not  always  attended 
by  the  production  of  pseudomembranes. 
The  intensity  of  the  local  action  of  the 
bacilli  varies  greatly,  and  it  has  been 
found  that  this  diphtheria  bacillus  may 
be  the  cause  of  simple  inflammatory 
processes,  formerly  designated  as  catar- 
rhal, which  present  no  appearance  of 
false  membranes.  Moreover  we  find  that 
the  all-important  question  in  any  case, 
both  with  reference  to  prognosis  and 
treatment,  is  the  presence  or  absence  of 
the  diphtheria  bacillus.  We,  therefore, 
abandon  the  former  classification  into 
catarrhal  and  pseudomembranous  proc- 
esses and  speak  of: — 

1.  Diphtheria,  or  true  diphtheria,  in 
which  we  include  all  oases  of  acute  in- 
flammations affecting  mucous  mem- 
branes associated  with  the  presence  of 
the  diphtheria  bacillus  in  sufficient 
number  to  constitute  a  probable  causa- 
tive agent.  Thus,  if  a  culture  from  a 
flore  throat  show  the   presence   of  the 


diphtheria  bacillus,  that  case  is  at  the 
present  time  accepted  as  diphtheria, 
whether  there  be  or  not  pseudomem- 
brane  present,  and  no  matter  what  other 
bacteria  be  associated  in  the  culture  with 
the  diphtheria  bacillus.  It  must,  how- 
ever, be  noted  that  the  presence  of  the 
diphtheria  bacillus  without  further  clin- 
ical evidence  does  not  constitute  diph- 
theria any  more  than  the  presence  of 
pneumococei  in  the  mouths  of  healthy 
persons  constitutes  pneumonia. 

Following  conclusions  are  based  upon 
a  study  of  1075  cases,  comprising  chil- 
dren of  all  ages  from  one  to  eighteen 
j'ears,  among  whom  were  encountered 
134  cases  of  clinical  diphtheria  and  from 
whom  were  obtained  8000  cultures.  Of 
these  children,  275  were  kept  in  absolute 
individual  isolation,  and  under  condi- 
tions admitting  of  the  most  careful  over- 
sight, in  which  the  chances  of  reinfection 
were  reduced  to  the  minimum.  While 
the  Klebs-LoefHer  bacillus  is  undoubtedly 
present  along  with  staphylococci  and 
several  other  varieties  of  bacilli  in  every 
case  of  diphtheria,  its  mere  presence  is 
no  guide  as  to  its  virulence  or  non- 
virulence.  This  bacillus,  or  one  morpho- 
logically identical  with  it,  is  present  in 
the  throats  in  nearly  one-third  of  all 
the  children  and  possibly  adults.  It  is 
found  as  frequently  in  the  throats  and 
noses  of  those  who  have  never  had  clin- 
ical diphtheria  as  in  those  who  have  sus- 
tained acute  attacks  of  the  disease,  but 
in  the  former  is  often  of  variant  type. 
J.  H.  Adair  (Northwestern  Lancet,  Sept. 
1,  '99). 

From  a  study  of  the  throat  cultures 
of  285  healthy  individuals,  7  of  which 
showed  the  presence  of  diphtheria  bacilli, 
and  of  190  Iiealthy  boys  whose  throat 
cultures  showed  the  presence  of  the 
Klebs-LocfTler  bacilli  in  only  10,  the  fol- 
low ing  conclusions  have  been  drawn: 
1.  Diphtheria  bacilli  are  seldom  found  in 
the  tliroats  of  those  who  have  not  been' 
exposed  to  diphtheria.  2.  The  bacilli 
are  more  frequently  found  in  those  who 
have  been  exposed,  especially  in  persona 
living  under  poor  hygienic  conditions  or 


DIPHTHERIA.    VARIETIES. 


499 


in  institutions.  3.  The  conditions  of 
institution  life  which  favor  the  growth 
of  the  bacilli  in  healthy  throats  are 
the  living  togetlier  ot  a  large  number 
of  persons  in  a  limited  air-space.  4. 
Healthy  individuals  with  virulent  bacilli 
in  their  throats  can  spread  the  disease. 
They  are  just  as  dangerous  as  mild  or 
convalescent  eases  of  diphtheria,  and 
ought,  therefore,  to  be  detected  and 
isolated.  5.  Cultures  ought  to  be  made 
among  those  who  have  been  exposed  to 
diphtheria;  (a)  by  physicians  among 
the  members  of  a  family  who  have  been 
exposed;  (6)  by  inspectors  in  the 
schools;  (c)  by  the  health  officers  under 
any  circumstances  when  they  think  the 
disease  is  being  or  may  be  spread  by 
such  individuals.  F.  P.  Denny  (Boston 
Med.  and  Surg.  Jour.,  Nov.  22,  1900). 

Not  only  are  there  definite  and  dis- 
tinct species  of  diphtheria  bacillus,  but 
each  species  has  distinct  subspecies  and 
varieties  with  characteristics  which  con- 
tinue to  persist  under  different  condi- 
tions. Thus,  varieties  as  well  as  spe- 
cies remain  separate,  and  when  grown 
imder  similar  conditions  the  species 
show  no  tendency  to  become  converted 
the  one  into  the  other,  while  the  varie- 
ties gradually  change,  approaching  a 
common  norm.  Since  in  a  series  of  ten 
cases  of  clinically  typical  diphtheria 
only  one  varietj'  of  the  specifically  viru- 
lent diphtheria  bacillus  was  obtained 
from  the  throat  of  each  case  through- 
out the  course  of  the  disease,  since  from 
different  parts  of  the  same  patient  only 
one  variety  was  isolated,  and  since 
pseudovarieties  were  found  no  more  fre- 
quently at  the  end  than  at  the  begin- 
ning of  the  disease,  it  is  safe  to  infer 
that  specifically  virulent  bacilli  do  not 
readily,  if  ever,  change  into  any  form 
of  non-virulent  diphtheria  bacilli  in 
throats  or  noses  of  people  during  an 
attack  of  diphtheria.  In  a  second  group 
a  number  of  healthy  throats  were  ex- 
amined and  many  distinct  varieties  of 
diphtheria-like  bacilli  were  found,  all  of 
which,  however,  in  serial  pure  culture, 
retained  their  characteristics.  From  a 
third  group  the  inference  was  drawn 
that  not  only  does  a  variety  of  the  ba- 
cillus retain  its  characteristics  for  some 


time   in   the   same   throat,   but  that  it 
may    be    transferred    to    other    throats 
without  losing  its  individuality.    Finally 
a    number    of    cultures    were    examined 
which  had  been  kept  in  the  laboratory 
for   years.     These   were   freshly   inocu- 
lated   every    few    days,    and    but    few 
changes  were  found  in  the  general  shape 
and   properties   of   the   bacilli,   as   com- 
pared with  the  original  observation.    A. 
W.  Williams    (Jour,  of  Med.  Research, 
June,  1902). 
2.    Pseudodiphiheria,  in  which  we  in- 
clude   all    cases    resembling    diphtheria 
but   not  showing  the   presence  of   the 
diphtheria  bacillus  in  cultures  from  the 
affected    parts.      Such    pseudomembra- 
nous inflammations  are  commonly  seen 
as  complications  of  the  acute  infectious 
diseases,    especially    scarlet    fever    and 
measles.    Cultures  from  such  cases  regu- 
larly show  the  presence  of  streptococci 
or  staphylococci  or  both.     The  strepto- 
cocci are  especially  frequent.     Pneumo- 
cocci    and    other    bacteria    have    been 
found. 

The  site  of  the  diphtheritic  process, 
whether  nose,  tonsils  or  pharj'ns,  or 
larynx,  materially  affects  the  symptoms 
and  course  of  the  disease;  we  therefore, 
in  our  description,  speak  of  nasal; 
pharyngeal,  or  tonsillar;  and  laryngeal 
diphtheria.  In  the  eifort  to  further 
classify  their  cases  some  divide  them 
upon  the  basis  of  the  bacteriological 
findings  in  cultures  from  the  throat. 
Thus,  when  the  culture  shows  diph- 
theria bacilli  practically  alone,  they 
designate  the  case  as  bacillary  diph- 
theria; when  cocci  are  present  in  con- 
siderable numbers  with  the  diphtheria 
bacilli,  as  coccobacillary  diphtheria, 
etc.  This  method  would  be  highly 
satisfactory  did  the  clinical  course  and 
outcome  of  the  disease  correspond  to 
the  bacteriological  findings,  but  they 
do  not.  The  presence  of  cocci  in  the 
cultures  does  not  show  tJiat  they  will 


500 


DIPHTHERIA.    SYMPTOMS. 


play  any  important  part  in  the  disease, 
and  the  complications  produced  by  their 
action — such  as  pneumonia  and  nephri- 
tis— seem  to  be  as  frequent  in  cases 
that  give  apparently  pure  cultures  of  the 
diphtheria  bacillus  from  the  throat  as 
in  those  that  show  many  cocci  as  well. 
When  we  have  to  do  with  a  systemic  in- 
fection with  streptococci  as  well  as  the 
diphtheria  bacilli,  we  speak  of  the  cases 
as  "mixed  infections";  but  the  distinc- 
tion is  based  upon  the  clinical  symptoms 
of  the  disease  and  not  upon  the  results 
of  the  bacteriological  examination.  We 
find  it  most  advantageous  to  divide  the 
cases  into  mild,  severe,  or  septic,  accord- 
ing to  the  character  of  the  symptoms 
presented. 

Corresponding  to  these  three  forms  of 
diphtheria,  Monti  presents  a  classification 
based  upon  the  character  of  the  exudate 
in  the  throat: — 

1.  A  fibrinous  form  in  which  the  diph- 
theritic products  are  only  placed  upon 
the  mucous  membrane,  not  incorporated 
with  it.  Virchow,  Weigert,  and  Cohn- 
heim  call  this  the  croupous  form. 

2.  A  mixed  form,  called  also  the 
phlegmonous  form,  in  which  the  fibri- 
nous exudate  lies  deep  in  the  tissues  as 
well  as  upon  the  mucous  membrane. 

A  septic,  or  gangrenous,  form,  in 
which  a  fibrinous  pseudomembrane  is 
formed  in  the  deep  tissues  of  the  mucous 
membrane,  the  process  really  consisting 
of  a  necrosis  of  the  tissues  and  a  mingling 
of  the  dead  particles  with  the  diphthe- 
ritic products. 

Similar  classifications  are  presented  by 
other  Continental  writers;  but  we  have 
not  yet  found  it  of  advantage  to  attempt 
to  classify  our  cases  by  the  local  appear- 
ances of  the  throat.  Certainly  the  dis- 
tinctions that  Monti  makes  call  for  very 
nice  and  rather  difficult  discriminations. 

Symptoms.  —  These   vary   sulTiciently 


with  the  site  of  the  lesions  to  make  it 
of  advantage  to  consider  the  local  forms 
separately. 

1.  Nasal  Diphtheria.  —  Diphtheria 
of  the  nasal  cavities  is,  in  most  cases, 
simple  extension  from  the  fauces,  or 
larynx.  It  may,  however,  occur  as  a 
primary  affection.  It  is  characterized  by 
more  or  less  complete  obstruction  of  the 
nares;  a  thin,  muco-purulent,  and  often 
bloody  discharge  from  the  nostrils;  and 
a  more  or  less  marked  toxtemia.  Pseudo- 
membrane  may  be  developed  and  may  be 
visible  through  the  anterior  nares,  but, 
as  a  rule,  we  see  no  membrane.  The 
nasal  discharge  is  usually  very  irritating 
and  the  nares  become  excoriated. 

The  degree  of  the  toxaemia  varies 
markedly.  Usually  it  is  very  moderate, 
the  temperature  is  not  high  (100°  or 
101°),  the  prostration  is  not  marked,  and 
the  chief  danger  of  the  cases  seems  to 
lie  in  an  extension  of  the  process  by  con- 
tinuity of  tissue,  to  the  pharynx  or 
larynx,  or  the  development  of  pneu- 
monia. 

The  affection  is  often  protracted,  the 
discharge  from  the  nose  and  the  obstruc- 
tion persisting  for  weeks,  despite  careful 
treatment. 

Lennox  Browne  reports  a  total  mortal- 
ity of  G3.4  per  cent,  in  a  series  of  cases  of 
diphtheria  involving  the  nose,  and  at- 
tributes to  the  nasal  affection  more  im- 
portance than  to  the  laryngeal.  Few 
writers  or  clinicians  can  agree  with  this 
opinion.  In  practically  all  the  cases  of 
the  series  reported  other  parts  were  in- 
volved besides  the  nares,  and  the  mor- 
tality-record is  a  tribute  to  the  gravity 
of  extensive  diphtheria  rather  than  to 
the  danger  of  the  nasal  affection  alone. 
In  infants,  however,  nasal  diplithcria  fre- 
quently proves  fatal.  It  may  readily  be 
the  origin  of  a  pharyngeal  or  laryngeal 
process.     It  may,  furthermore,  be  the 


DIPHTHERIA.    SYMPTOMS. 


501 


means  of  communicating  the  disease  to 

others. 

Primaiy  diphtheria  of  tlie  nose  is  dis- 
tinct from  diphtheritic  rhinitis  when 
complicating  faucial  diphtheria.  It 
usually  involves  both  nostrils,  but  rarely 
spreads  into  the  pharynx  or  larynx.  It 
differs  from  the  so-called  "membranous" 
or  croupous  rhinitis  chiefly  bacteriolog- 
ically,  but  more  carefully,  and  frequent 
examinations  tend  to  show  the  same 
relation  between  these  two  as  between 
membranous  croup  and  laiyngeal  diph- 
theria. The  diagnosis  is  not  difficult  on 
a  careful  rhinoscopic  inspection  and  is 
coiToborated  by  one  or  more  bacteriolog- 
ical examinations.  The  constitutional 
disturbances  are  usually  mild  except 
during  the  onset,  when  they  resemble, 
and  are  usually  mistaken  for,  a  violent 
coryza.  Antitoxin  is  not  usually  admin- 
istered on  account  of  the  mildness  of  the 
disease,  but  to  shorten  its  deviation 
and  diminish  the  danger  of  infection. 
W.  Scheppegrell  (Trans.  Amer.  Med. 
Assoc,  May,  1903). 

2.  Pharyngeal,  or  Tonsillar, 
Diphtheria. — (A)  Mild  Cases  Without 
Memlrane,  or  Catarrhal  Diphtheria. — 
During  the  prevalence  of  an  epidemic 
of  diphtheria,  especially  in  institutions, 
a  certain  number  of  cases  may  be  ob- 
served in  which,  without  the  appearance 
of  pseudomembrane,  the  pharynx  and 
tonsils  become  reddened  and  somewhat 
swelled,  the  children  complain  of  slight 
soreness  of  the  throat  and  have  a  rise 
in  temperature,  biit  do  not  appear  or 
feel  very  ill;  yet  cultures  made  from 
such  throats  show  the  presence  of  the 
diphtheria  bacillus.  Such  cases  we  have 
learned  to  class  as  true  diphtheria.  The 
mildness  of  the  affection  is  attributed 
either  to  the  small  number  of  bacilli 
present,  to  a  diminution  in  the  viru- 
lence of  the  bacilli,  or  to  an  increased 
resistance  on  the  part  of  the  patient.  In 
many  of  these  cases  the  nose  is  involved 
as  well  as  the  pharynx  and  tonsils,  and 
there  is  consequently  a  thin,  watery,  irri- 


tating discharge  from  the  nostrils.  In 
the  course  of  a  few  days  all  symptoms 
subside,  and  the  bacilli  disappear,  or 
they  may  persist  for  weeks  without  fur- 
ther symptoms. 

Series  of  20  children  in  which  the  ba- 
cillus was  found  in  6  on  admission,  while 
in  the  other  14  cases  it  was  discovered  at 
times  varying  from  a  few  days  to  several 
weeks  after  admission.  The  infants  in 
whom  the  bacilli  were  present  in  the 
mouth  presented  no  symptoms,  either 
general  or  local.  These  bacilli  often  re- 
mained for  several  weeks,  and  even 
months  (in  one  case  two  and  a  half 
months),  in  an  indolent  condition,  al- 
though in  several  cases  they  declared 
themselves  in  a  virulent  manner.  Of 
the  6  children  who  arrived  at  the  hos- 
pital with  diphtheria  bacilli  already  in 
the  mouth,  only  1  came  from  a  family 
in  which  there  had  been  a  case  of  diph- 
theria five  weeks  previously;  2  came 
from  a  house  infected  by  measles,  and 
the  remaining  3  had  not  been  in  con- 
tact with  any  eases  of  infectious  disease. 
In  12  cases  the  bacteriological  examina- 
tion was  supplemented  by  inoculation  of 
animals.  The  bacilli  found  in  0  cases 
were  so  virulent  as  to  cause  the  death 
of  the  animals  in  from  twenty-four  to 
forty-eight  hours,  while  in  the  other  6 
cases  the  virulence  was  only  of  medium 
intensity.  Heubner  (Jahrb.  f.  Kinderh., 
B.  43,  8.54). 

The  bacilli  derived  from  cultures  from 
such  cases  may  prove  to  be  fully  virulent, 
and  any  such  case  may  readily  be  the 
means  of  communicating  a  severe  or  viru- 
lent type  of  the  disease  to  others. 

The  patients  themselves  may  show  al- 
buminuria during  the  course  of  their 
mild  attack,  or  they  may  later  develop 
the  paralyses  belonging  to  the  severer 
types  of  diphtheria.  The  latter  out- 
come is,  fortunately,  rare. 

From  the  catarrhal  process  in  the 
throat  and  nose  there  may  arise  by  ex- 
tension a  diphtheritic  laryngitis  either 
catarrhal  or  pseudomembranous  in  char- 


503 


DIPHTHERIA.    SYIIPTOJIS. 


acter,  which  may  be  followed  by  stenosis 
or  other  grave  sjinptoms. 

(B)  Mild  Cases,  with  MembranCf  of 
Pharyngeal,  or  Tonsillar,  Diphtlieria. — 
These  cases  are  characterized  by  the  de- 
velopment of  more  or  less  pseudomem- 
brane  upon  the  tonsils,  fauces,  or 
phar}-nx,  and  a  moderate  toxaemia.  The 
onset  of  the  trouble  is  marked  by  sore 
throat;  a  moderate  fever,  100°  or  102°; 
and  a  slight  prostration.  Fpon  examin- 
ing the  throat  we  usually  find  one  or 
both  tonsils  reddened,  swelled,  and  pre- 
senting upon  their  surfaces  one  or  more 
patches  of  pseudomembrane.  These 
patches  may  be  small  and  difficult  to 
distinguish  from  the  yellow  plugs  seen 
in  follicular  tonsillitis.  The  membrane 
is  usually  firmly  adherent  to  the  under- 
ling tissue,  and,  if  removed,  leaves  a 
bleeding  surface.  The  area  covered  by 
membrane  may  sometimes  be  marked  off 
from  the  surrounding  tissues  by  a  zone 
of  congestion.  The  membrane  is  usually 
white-gray,  or  grayish-green  in  color, 
sometimes  yellow,  and  the  patches  are 
of  irregular  form.  It  is  sometimes  thick 
and  heavy,  sometimes  so  thin  as  to  be 
translucent.  Over  against  this  descrip- 
tion of  diphtheritic  membrane  we  might 
set  the  characters  of  pseudomembrane 
not  diphtheritic,  but  the  more  painstak- 
ing the  description,  the  more  evident 
would  it  become  that  it  is  perfectly  im- 
possible to  distinguish  one  from  the 
other  by  simple  inspection.  Nothing 
short  of  a  bacteriological  examination 
will  enable  us  to  make  the  distinction 
with  certainty. 

The  presence  of  the  LoeHler  bacillus 
is  a  sure  sign  that  tlie  accompanying 
pseudomembranous  inflammation  is  diph- 
theritic; the  bacillus  of  diphtheria  may 
be  present  without  causing  symptoms  of 
the  disease;  the  bacillus  may  disappear 
when  the  symptoms  cease,  or  may  con- 
tinue in  a  virulent  state  for  months  upon 


the     fauces     of     the     infected     person. 
Loeffler  (Lancet,  Sept.  S,  '94). 

With  such  appearances  in  the  throat 
there  is  usually  a  distinct  swelling  and 
tenderness  of  the  submaxillary  and  cer- 
vical lymph-nodes. 

The  extent  of  membrane  in  the  mild 
cases  is  usually  limited,  and  there  seems 
little  tendency  toward  spreading;  but, 
on  the  other  hand,  we  may  see  cases  in 
which  tonsils,  fauces,  and  pharynx  are 
covered  with  membrane  and  yet  the  con- 
stitutional depression  is  slight. 

After  the  onset  in  a  mild  case  the 
membrane  may  extend  somewhat,  so  as 
to  involve  the  fauces  or  pharynx;  but 
may  remain  limited  to  the  tonsils.  The 
throat  continues  sore,  the  temperature 
shows  some  elevation,  and  the  children 
feel  moderately  sick.  In  the  course  of 
three  to  five  days  the  membrane  begins 
to  separate,  either  gradually  or  in  masses, 
the  throat  clears  up,  the  temperature 
falls,  the  glandular  swelling  subsides,  and 
in  a  week  or  so  the  patient  is  well  again. 

A  mild  diphtheria  may  be  accom- 
panied by  albuminuria,  and  may  be  fol- 
lowed by  nephritis  or  paralysis,  but,  as 
a  rule,  the  cause  is  benign  and  the  out- 
come satisfactory.  We  must,  however, 
be  prepared  at  any  time  to  see  an  appar- 
ently mild  case  of  diphtheria  change 
character  and  become  a  virulent  infec- 
tion. From  a  mild  tonsillar,  or  pharyn- 
geal, diphtheria  a  severe  diphtheritic 
laryngitis  may  be  developed. 

The  most  troublesome  features  of 
these  mild  cases  of  diphtheria  is  the 
difficulty  of  maintaining  proper  quaran- 
tine. If  adults,  the  patients  do  not  re- 
gard themselves  sick  after  the  first  day 
or  two,  and  can  hardly  be  made  to  under- 
stand that  oven  when  well  they  may  be 
the  source  of  grave  danger  to  others. 

If  the  patients  are  children,  the  par- 
ents find  it  difficult  to  take  a  serious  view 


DIPHTHERIA.    SYJIPTOMS. 


503 


of  an  apparently  trifling  sore  throat  and 
are  often  unwilling  to  take  the  necessary 
precautions  to  prevent  the  spread  of  the 
disease.  It  cannot  be  too  emphatically 
laid  down  in  such  cases  that  the  clinical 
phenomena  arc  no  test  of  the  virulence 
of  the  bacteria  present.  From  an  appar- 
ently mild  case  Para  obtained  the  most 
virulent  bacillus  he  has  yet  met  with, 
and  employed  its  toxins  in  the  produc- 
tion of  antitoxin  of  unusual  strength. 
It  has  likewise  long  been  well  known 
that  an  apparently  mild  case  of  diph- 
theria may  communicate  a  malignant  in- 
fection to  others. 

The  mild  cases  should  be  quarantined 
just  as  faithfully  as  the  most  severe,  and 
should  be  allowed  freedom  only  when 
the  specific  bacteria  have  disappeared 
from  the  throat. 

(C)  The  Severe  Cases. — In  these  the 
manner  of  onset  may  be  sudden,  with 
chill,  vomiting,  fever,  and  severe  sore 
throat,  the  temperature  rising  to  103°- 
104°,  and  the  prostration  being  marked, 
or  the  affection  may  begin  as  a  mild  case 
and  gradually  develop  the  severe  symp- 
toms, the  invasion  being  very  insidious. 
If  seen  at  the  beginning,  there  may  be 
little  membrane  visible  in  the  throat, 
only  a  small  patch  or  two  upon  the  ton- 
sils, exactly  similar  to  that  described  in 
the  mild  cases;  the  throat  will,  how- 
ever, be  more  reddened  and  the  swelling 
more  marked.  The  submaxillary  and 
cervical  lymph-nodes  will  be  swelled  and 
tender.  The  child  locks  and  acts  sick. 
The  elevation  of  temperature  may  not 
be  in  keeping  with  the  degree  of  consti- 
tutional depression,  oftentimes  being 
only  101°  to  102°.  As  the  disease  de- 
velops, the  membrane  rapidly  extends, 
until  the  tonsils,  pharynx,  uvula,  and 
fauces  are  covered  with  a  thick  gray, 
green,  or  even  black  layer  of  necrotic 
material.     If  anv  effort  be  made  to  re- 


move it  the  underlying  tissues  bleed 
freely.  The  membrane  fills  the  rhino- 
pharynx,  involves  the  nasal  cavities,  and 
may  even  appear  in  the  nares.  With  the 
involvement  of  the  nose  there  is  seen  a 
thin,  acrid,  often  bloody  and  foul-smell- 
ing discharge  from  the  nostrils.  The 
membrane  may  also  invade  the  mouth 
and  appear  upon  the  lips.  In  one  case 
seen  at  the  Foundling  Hospital,  the  ex- 
tent of  gray  membrane  upon  the  lips, 
cheeks,  and  tongue  was  so  marked  as  to 
suggest  the  possibility  that  the  child  had 
been  drinking  carbolic  acid.  Mechan- 
ical removal  of  the  membrane  in  such 
cases  does  no  good  whatever;  it  seems 
only  to  open  up  a  fresh  surface  to  the 
attack  of  the  virulent  bacilli,  and  the 
membrane  is  reproduced  with  almost 
marvelous  rapidity.  At  any  time  the 
inflammatory  process  may  involve  the 
larynx,  giving  rise  to  laryngeal  diph- 
theria, or  it  may  involve  the  middle  ear 
through  the  Eustachian  tubes;  in  rare 
cases  by  extension  through  the  lacrjTnal 
duct  or  by  accidental  inoculation  the 
conjunctiva  is  involved. 

With  the  increase  in  the  local  process 
the  lymph-nodes  of  the  neck  become 
more  swelled  and  tender,  until  it  seems 
that  they  will  surely  suppurate,  but  they 
rarely  do  so.  The  constitutional  depres- 
sion becomes  more  and  more  marked. 
The  pulse  becomes  more  rapid  and 
feeble;  the  strength  fails  steadily. 

Eight  hundred  consecutive  cases  of 
dipl\theiia  observed.  Less  than  half  of 
the  cases  in  which  the  pulsc-iate  ex- 
ceeds 100  recover.  The  pulse-rate  and 
the  mortality  appear  to  be  very  much  in 
a  direct  ratio  to  each  other,  and  recov- 
ery is  improbable  when  the  pulse  gets 
above  InO.  Extreme  slowness  of  the 
pulse  is  less  significant;  but  in  children 
bradycardia  does  at  times  presage  evil. 
Variations  of  rhythm  and  volume  occur 
in  some  10  per  cent,  of  all  cases,  and  are 
a    useful    premonition    of    cardiac    com- 


504 


DIPHTHERIA.     SYIIPTOMS. 


plications.     A   systolic   murmur   at   the 
apex  of  the  heart  is  heard  in  about  one 
case  in  ten;  its  significance  depends  en- 
tirely upon  its  cause.     This  is  far  more 
commonly  mitral  insufficiency,  due  either 
to  weakness  and  inadequate  contraction 
of  the  cardiac  muscle,  or  to  dilatation  of 
the  left  ventricle,  but  in  rare  instances 
to  an  endocarditis  ot  diphtherial  origin. 
Hibbard   (Boston  Med.  and  Surg.  Jour., 
Jan.  27,  Feb.  o,  "98). 
The  temperature  may  not  at  any  time 
be  very  high,  101°  or  102°,  or  it  may 
reach  103°  or  105°.     The  swelling  and 
tenderness  of  the  throat  render  swallow- 
ing painful  and  sometimes  almost  im- 
possible.    The  tonsils  may  almost  meet 
in  the  median  line,  the  nostrils  may  be 
plugged  and  even  respiration  seriously 
interfered  with.     At  times  in  the  early 
days  of  the  disease  we  may  see  fluids 
regurgitate  through  the  nose,  when  any 
attempt  to  drink  is  made,  and  it  may  be 
difficult  to  determine  whether  the  regiir- 
gitation  is  due  to  the  obstruction  of  the 
throat  by  the  swelled  tonsils  or  to  an 
early  paralysis  of  the  pharyngeal  muscles. 
As  the  diphtheria  advances,  the  urine 
becomes  scanty  and  high  colored,  and 
contains  albumin  in  some  quantity;    at 
times  an  acute  exudative  nephritis  is  de- 
veloped, with  large  quantities  of  albu- 
min, casts,  and  even  blood.     The  onset 
of  the  complication  may  bring,  in  its 
train,  all  the  symptoms  of  an  acute  ne- 
phritis. 

Examinations  made  for  albuminuria  in 
279  cases  of  diphtheria,  it  being  found 
in  131 ;  rate  of  mortality,  50.37  per  cent. 
No  evidence  of  albuminuria  could  be 
discovered  in  148  cases, — the  rate  of  mor- 
tality here  being  14.2  per  cent.  Cases 
free  from  albuminuria  thiis  afTord  a 
more  favorable  prognosis.  Baginsky 
(Archiv  f.  Kinderh.,  B.  10,  H.  3-C,  '93). 
Kcsults  of  examination  of  1000  urines 
in  diphtheria  liy  botli  Eeliling's  test  and 
the  phenyl liydrazin  test.  In  230  cases 
examined  reaction  was  noted  in  2r>  per 
cent,  of  all  cuhchj  in  those  that  recovered 


it  was  obtained  in  19  per  cent.;  and  in 
the  fatal  cases  in  77  per  cent.  In  cases 
without  false  membrane  no  reaction  was 
obtained. 

In  a  second  series  of  96  cases  a  positive 
reaction  was  obtained  in  33  cases  by  both 
tests. 

The  glycosuria  was  often  associated 
with  albuminuria.  A  certain  number  of 
cases  were  examined  before  and  after  the 
injection  of  antitoxin,  and  it  was  found 
that  for  a  few  days  after  the  injection 
a  slight  glycosuria  sometimes  occurred. 
Hibbard  and  Morrissey  {Jour,  of  Exper. 
Med.,  Jan.,  '99). 

Diphtheritic  albuminuria  has  no  other 
relation  to  diphtheritic  paralysis  than 
that  both  complications  are  more  prone 
to  occur  when  the  diphtheritic  intoxica- 
tion is  most  intense.  E.  F.  Trevelyan 
(Lancet,  Nov.  24,  1900). 

The  mind  may  remain  clear  through- 
out; but,  as  a  rule,  with  the  deepening 
of  the  toxaemia  the  patients  become  dull 
and  listless.  In  the  severest  cases  stu- 
por or  delirium  may  be  developed.  Coma 
is  rarely  seen.  Convulsions  may  occur 
either  early  or  late  in  the  disease,  from 
the  toxaemia  of  the  diphtheria  or  from 
iirsemia. 

In  some  cases  the  patients  die  from 
the  diphtheria  toxasmia  alone;  but  in 
most  of  the  fatal  cases  one  or  the  other 
of  the  complications  is  the  direct  cause 
of  death.  Most  important  of  these  is 
the  pneumonia.  Although  most  often 
seen  in  laryngeal  cases,  pneumonia  is  a 
common  sequel  of  diphtheria,  either 
nasal  or  pharyngeal.  The  onset  of  the 
broncho-pneumonia  is  usually  marked 
by  a  decided  rise  in  the  temperature,  a 
quickened  respiration,  and  some  cough. 
Not  till  the  pneumonia  has  advanced  to 
the  consolidation  of  large  areas  do 
definite  physical  signs  attest  its  presence. 
Usually  we  hear  more  or  less  numerous 
fine  crackling  rales  over  one  or  both 
chests  posteriorly.  Later  there  may  be 
scattered  areas  of  dullness,  with  brnn- 


DIPHTHERIA.     SYMPTOMS. 


505 


chial  voice  and  breathing.  For  evidence 
of  the  onset  we  must  depend  upon  the 
rational  rather  than  tiie  physical  signs. 
The  development  of  pneumonia  is  al- 
ways a  grave  and  often  a  fatal  complica- 
tion. In  but  few  fatal  cases  do  we  fail 
to  find  a  more  or  less  extensive  involve- 
ment of  the  lungs,  and  in  the  greater 
number  it  plays  an  important  part  in 
the  unhappy  outcome. 

If  the  view  at  present  generally  held, 
that  the  complicating  pneumonia  is  de- 
pendent upon  the  action  of  streptococci 
and  not  upon  that  of  the  diphtheria 
bacillus  itself,  and  therefore  antitoxin- 
can  only  indirectly  affect  its  onset  or  its 
violence,  be  true,  then  the  problem  of 
further  reducing  the  mortality  of  diph- 
theria must  depend  upon  the  solution  of 
the  prevention  and  treatment  of  this 
complication.  At  present  it  is  of  im- 
portance to  watch  for  signs  of  its  onset 
and  to  be  prepared  to  take  measures  to 
limit  its  extension  and  enable  the  pa- 
tient to  bear  the  attack.  The  most 
malignant  eases  of  diphtheria  die  within 
forty-eight  hours  of  the  onset  of  the 
disease,  and  even  in  these  we  find  more 
or  less  extensive  areas  of  broncho-pneu- 
monia. Most  of  the  fatal  cases  termi- 
nate after  five  or  ten  days,  the  patients 
being  exhausted  by  the  toxemia  of  the 
disease  or  the  pneumonia. 

In  the  more  favorable  cases  improve- 
ment usually  begins  about  the  fourth  or 
fifth  day.  The  change  is  shown  in  both 
the  blood  and  the  general  condition. 
In  the  throat  the  membrane  ceases  to 
extend  and  begins  to  separate.  The 
separation  begins  upon  the  edge  of  each 
patch,  the  separated  portions  forming 
loosened  tags  in  the  nose  or  throat,  or 
the  membrane  may  come  away  en  masse 
in  the  form  of  casts  of  the  afTected  parts. 
The  surface  beneath  the  membrane  is 
at  first  raw  and  bleeding,  but  is  usu- 


ally quickly  covered  by  new  epithelium. 
On  the  tonsils,  however,  ulcers  are 
formed,  which,  healing  slowly,  leave 
irregular,  depressed  areas  of  cicatricial 
tissue,  giving  to  the  tonsils  the  ex- 
cavated appearance  so  often  seen  after 
severe  diphtheria.  With  the  separation 
of  the  membrane  the  purulent  discharge 
from  nose  and  mouth  gradually  ceases, 
but  a  catarrhal  secretion  may  continue 
for  weeks  afterward,  such  catarrhal 
secretion  still  containing  virulent  ba- 
cilli. 

With  the  change  in  the  local  condi- 
tion the  temperature  gradually  falls,  the 
pulse  improves,  the  glandular  swellings 
subside,  the  dullness  or  stupor  disappear, 
and  at  the  end  of  the  second  or  third 
week  the  patient  is  convalescent.  The 
patients  are  usually  left  very  anoemic, 
and  the  return  to  health  is  likely  to  be 
slow. 

From  time  to  time  we  see  cases  in 
which  the  formation  of  membrane  con- 
tinues for  two  or  three  weeks,  the  course 
of  the  disease  is  protracted  and  recovery 
correspondingly  delayed.  In  other  cases 
the  broncho-pneumonia  persists  long 
after  the  disappearance  of  all  evidences 
of  the  diphtheria,  and  may  either  cause 
death  from  exhaustion  or  may  slowly 
dissolve. 

3.  Cases  of  Mixed  Infectiox,  or 
Septic  Diphtheria. — Under  this  head 
are  grouped  those  cases  in  which  bac- 
teriological investigation  shows  the  pres- 
ence of  the  diphtheria  bacillus,  together 
with  other  pathogenic  bacteria,  usually 
streptococci,  in  some  cases  pneumococci, 
and  in  which  these  additional  organisms 
seem  to  exert  a  definite  influence  upon 
the  course  of  the  disease.  Most  of  these 
cases  are  fatal  and  in  post-mortem  ex- 
aminations systemic  infection  with  strep- 
tococci or  pneumococci  is  said  to  be 
found.     The  appearance  of  the  mem- 


506 


DIPHTHERIA.     SYMPTOMS. 


brane  in  these  cases  does  not  differ 
essentially  from  that  seen  in  the  severer 
forms  of  infection  with  the  diphtheria 
bacillus  alone.  It  may  be  white,  yellow, 
gray,  or  oliTe  colored,  or,  where  hemor- 
rhages accompany  the  inflammatory 
process,  more  or  less  black.  The  mem- 
brane is  usually  extensive,  covering  the 
tonsDs,  pharynx,  fauces,  and  uvula.  The 
swelling  of  the  affected  parts  is  usually 
very  marked,  the  oedema  being  pro- 
nounced, the  tonsils  often  so  filling  the 
throat  as  to  preclude  examination  of 
the  pharjTix  and  giving  rise  to  dyspha- 
gia and  dyspnoea.  There  is  the  same 
muco-purulent  or  bloody  discharge  from 
the  nose  and  mouth;  the  nares  are  ob- 
structed and  the  patients  often  breathe 
only  through  the  mouth.  A  peculiar 
sickening,  sweetish  foetor  is  character- 
istic. The  lymphatic  nodes  and  cellular 
tissues  of  the  neck  are  most  commonly 
swelled  and  indurated,  the  process  in 
many  cases  leading  on  to  suppuration 
and  occasionally  to  gangrene.  The  press- 
ure upon  the  veins  of  the  neck  may 
produce  congestion  of  the  head  and 
swelling  of  the  face.  The  swelled,  dusky 
features,  with  the  sanious  discharge  from 
nose  and  mouth,  is  characteristic  and  im- 
pressive. 

The  constitutional  symptoms  are  those 
of  a  profound  septicaemia.  The  tem- 
perature often  runs  as  high  as  104°  or 
106°,  but  may  not  be  remarkable.  The 
pulse  is  rapid,  feeble,  and  compressible. 
With  the  feebleness  of  the  pulse,  the 
extremities  may  be  cold  and  pale,  in 
marked  contrast  to  the  dusky  face. 
Vomiting  and  diarrhoea  are  common, 
and  may  be  persistent.  The  urine  con- 
tains considerable  albumin  and  casts, 
and  in  some  cases  blood.  The  quantity 
may  be  diminished;  suppression  may 
occur  and  cause  death  from  uraemia. 
GiJdema  of  feet  or  hands  may  be  seen. 


The  liver  and  spleen  may  both  be  en- 
larged. The  cerebral  symptoms  are 
marked.  The  patients  are  usually  dull 
and  stupid,  indiilerent  to  their  condi- 
tion or  surroundings,  but  at  times  they 
are  delirious  and  extremely  restless, 
tossing  continually  from  side  to  side  or 
crying  out  as  though  in  pain.  Broncho- 
pneumonia is  very  common  and  usually 
hastens  death.  At  any  time  during  the 
course  of  the  disease  the  larynx  may  be 
involved  by  extension.  The  cases,  as  a 
rule,  terminate  fatally  within  a  week, 
sometimes  within  forty-eight  hours. 
Eapid  failure  in  the  strength  of  the 
heart  marks  the  fatal  progress  of  the 
disease,  and  the  end  may  be  brought 
about  by  sudden  and  unexpected  syn- 
cope. If  they  survive  the  first  violence 
of  the  infection,  these  cases  are  espe- 
cially liable  to  complications  attributed 
to  the  pathogenic  action  of  the  strepto- 
cocci, such  as  suppuration  of  the  cervical 
lymph-nodes  and  cellular  tissues,  bron- 
cho-pneumonia, and  nephritis. 

Results    of    the    examination    of    234 

cases   of  membranous   angina   baeterio- 

logically : — 

1.  Loefflei's  bacillus  was  absent  in  20 
cases,  there  being  present  staphylococci, 
streptococci,  pneuniococci,  and  bacillus 
coli  communis.  Two  died, — 1  of  menin- 
gitis. Excluding  this  1,  the  mortality 
was  3.84  per  cent. 

2.  Loelller's  bacillus  occurred  alone  in 
102  cases;  mortality  28,— 27.4.'>  per  cent. 

3.  Loefller's  bacillus  found  in  associa- 
tion with  the  staphylococcus  pyogenes 
in  70  cases;  mortality  25,-32.89  per 
cent. 

4.  Loedler's  bacillus  found  with  .strep- 
tococcus i)yogenes  in  20  cases;  mortality 
0,-30  per  cent. 

5.  LocHler's  bacillus  with  streptococ- 
cus and  pneumococcus  (Frllnkel's)  in 
7  cases;   mortality  3, — 43  per  cent. 

0.  Loedler's  bacillus  with  bacillus  coli 
comuuinis  found  in  3  cases,  all  of  which 
ended    fatally.      ]3e    Blasi    and    Russo- 


DIPHTHEIilA.    SYMPTOMS. 


507 


Travail    (Riforma   Med.,   Nos.    179,   180, 
'9G). 

4.  Laryngeal  Diphtheria.  —  The 
clinical  picture  of  laryngeal  diphtheria 
does  not  present  such  variety  as  is  seen  in 
diphtheria  of  the  pharj'nx  and  tonsils. 
The  local  effects,  due  to  the  anatomical 
form  and  structure  of  the  larynx  and  its 
physiologic^  function,  predominate  over 
the  constitutional  symptoms.  The  mu- 
cous membrane  of  the  larynx  possesses 
but  little  absorptive  power;  so  that  as 
long  as  the  diphtheritic  process  is  lim- 
ited to  the  larynx  the  toxsemia  is  slight. 

From  what  has  been  already  said  it 
is  evident  that  we  may  have  laryngeal 
diphtheria: — 

1.  As  a  primary  affection. 

2.  As  an  extension  of  a  process  be- 
ginning either  in  the  nose  or  the  throat. 

It  may  also  occur: — 

3.  As  a  complication  of  other  infec- 
tious diseases,  especially  measles  or  scar- 
let fever.  In  the  latter  relation  it  is  less 
common  than  the  pseudomembranous 
laryngitis  produced  by  the  action  of 
staphylococci  or  streptococci  (pseudo- 
diphtheria),  and  occurring  as  a  complica- 
tion it  presents  itself  in  one  of  the  two 
preceding  ways,  either  primarily,  or  sec- 
ondarily to  diphtheria  of  the  nose  or 
throat. 

Diphtheria  of  the  larynx  begins  gradu- 
ally with  a  hoarse  cough  and  voice,  and 
perhaps  a  slight  stridor  with  inspiration. 
The  temperature  is  usually  low, — 99°  to 
101°, — and  the  child  does  not  appear 
very  sick.  The  early  stages  are  not  to  be 
clinically  distinguished  from  acute  catar- 
rhal laryngitis,  except  that  the  onset  of 
the  latter  is  usually  more  abrupt  and 
the  temperature  higher, — 102°  to  103°. 
The  course  of  diphtheritic  laryngitis  has 
the  following  rather  characteristic  se- 
quence of  symptoms:  Croupy  cough, 
croupy  inspiration,  aphonia,  stridulous 


expiration,  suprasternal  and  infrastemal 
recessions,  restlessness  and  jactitation, 
and  cyanosis.  The  cough  becomes  more 
and  more  hoarse,  the  voice,  at  first 
hoarse,  fails  steadily  until  the  aphonia 
becomes  complete;  the  stridor,  at  first 
only  affecting  inspiration,  shows  itself 
with  expiration  and  becomes  louder. 
With  the  increase  in  the  local  symptoms, 
the  temperature  may  continue  low  or 
may  mount  step  by  step  to  104°  or  more. 
At  the  end  of  the  first  or  second  day  the 
symptoms  of  laryngeal  stenosis  become 
well  developed.  The  voice  is  sunk  to  a 
whisper  or  lost  altogether,  the  cough  is 
very  hoarse  and  short  (tight),  there  is 
loud  stridor  with  both  inspiration  and  ex- 
piration, and  every  effort  to  fill  the  chest 
grows  slower  and  more  labored.  With 
each  inspiration  there  is  more  or  less 
marked  depression  of  the  suprasternal, 
and  supraclavicular  spaces  and  the  epi- 
gastrium. The  finger-tips  are  blue,  the 
lips  livid,  the  face  pale,  the  forehead  and 
perhaps  the  whole  body  bathed  in  per- 
spiration as  the  child  struggles  to  over- 
come the  increasing  obstruction  to  res- 
piration. The  perfect  clearness  of  mind 
is  in  marked  contrast  to  the  dullness  or 
stupor  usually  seen  in  severe  types  of 
diphtheria  elsewhere.  As  the  agony  in- 
creases, the  child  sits  up,  supporting  the 
shoulders  by  the  arms  to  give  free  play 
to  all  the  accessory  muscles  of  respira- 
tion, or,  wild  with  fear,  throws  himself 
from  side  to  side  or  up  and  down  in  a 
vain  effort  to  shake  off  the  tightening 
grip  upon  his  larynx.  It  cannot  be  too 
strongly  laid  down  that  the  laryngeal 
stenosis  seen  in  these  cases  is  largely  the 
result  of  spasm  of  the  laryngeal  muscles 
excited  refle.xly  by  the  inflammator}' 
process  and  in  small  part  the  result  of 
mechanical  obstruction  by  membrane  or 
the  swelling  and  oedema  that  accom- 
pany it.     Often  we  see  fatal  cases  of 


50S 


DIPHTHEKIA.     COMPLICATIONS  AND  SEQUEL.*;. 


laryngeal  diphtheria,  in  which  the  ste- 
nosis has  required  operative  treatment, 
showing  only  a  fine  granular  membrane, 
the  lumen  of  the  larynx  still  wide.  How 
much  swelling  and  oedema  may  disap- 
pear at  the  time  of  death  we  cannot  say, 
but  certainly  membrane  alone  rarely 
obstructs  the  larynx.  This  view  is 
strengthened  by  the  common  experience 
that  any  excitement  greatly  intensifies 
the  severity  of  the  stenosis.  A  child  may 
sleep  quite  comfortably  though  breath- 
ing stridulously  and  with  some  labor; 
waken  it  and  with  the  first  frightened 
cry  the  larj'nx  closes  as  though  in  a 
vise,  and,  unless  the  child  be  quickly 
quieted,  operative  relief  will  soon  be  re- 
quired. This  point  is  dwelt  upon  at 
such  length  for  the  purpose  of  enforcing 
its  consideration  in  treatment.  Quiet 
will  do  a  great  deal  in  controlling  ad- 
vancing stenosis.  Vomiting  will,  for  a 
time,  relax  the  spasm,  but  in  true  diph- 
theria the  stenosis  rapidly  returns.  At 
any  time  the  severity  of  the  stenosis 
may  relax,  the  symptoms  all  gradually 
subside,  and  the  patient  go  on  to  make 
a  good  recovery,  but,  unless  relieved  by 
treatment,  the  cases  usually  end  in 
death  by  suffocation.  In  such  a  case 
the  cyanosis  deepens,  the  respiration  be- 
comes more  and  more  labored,  the  vio- 
lent struggles  for  air  cease,  the  patients 
sink  into  stupor,  convulsions  develop, 
and  death  soon  follows. 

Such  an  outcome  is  most  common  in 
infants,  who  usually  succumb  in  from 
twenty-four  to  forty-eight  hours  from 
the  onset.  In  other  cases  the  course  is 
slower;  the  disease  reaches  its  height  in 
from  two  to  three  days  and  terminates 
within  a  week. 

Broncho-pneumonia  is  a  common  com- 
plication of  laryngeal  diphtheria.  It 
may  develop  as  the  result  of  direct  ex- 
tension   of    the    memljrane    from    the 


larynx  to  the  trachea  and  bronchi,  or  it 
may  result  from  the  inspiration  of  the 
inflammatory  exudate  containing  patho- 
genic bacteria.  The  mode  of  its  devel- 
opment cannot  be  clinically  determined. 
Its  presence  is  indicated  by  heightened 
temperature,  more  rapid  respiration, 
greater  cyanosis,  usually  numerous 
coarse  or  subcrepitant  rales  over  both 
chests  posteriorly,  and  more  marked 
prostration.  It  makes  the  prognosis 
much  more  grave  in  any  case  and  fre- 
quently causes  death  when  the  stenosis 
has  been  relieved  by  operation.  It  was 
one  of  the  late  Dr.  O'Dwyer's  observa- 
tions that,  in  descending  diphtheria, 
when  the  membrane  passed  from  the 
trachea  into  the  median  bronchi,  this 
invasion  of  a  new  territory  was  marked 
by  a  rapid  rise  of  temperature  which,  in 
turn,  was  soon  followed  by  developing 
pneumonia. 

When  laryngeal  diphtheria  develops 
secondarily  to  diphtheria  of  the  nose  or 
throat,  or  as  a  complication  of  the  in- 
fectious diseases,  the  symptoms  above 
described  are  superadded  to  those  of  the 
original  affection,  and  the  patient  is  all 
the  less  likely  to  survive. 

Complications  and  Sequelae.  —  Otitis 
media  is  an  occasional  complication  of 
diphtlicria.  It  is  developed  by  direct 
extension  of  the  inflammatory  process 
through  the  Eustachian  tubes  and  be- 
longs to  cases  in  which  the  rhino- 
pharynx  is  involved  in  the  diphtheritic 
process. 

The  middle  ear  ia  very  commonly 
alTeeted  in  diphtheria;  but  the  onset  of 
the  invasion  is  free  from  jjronounced 
syinptoniH,  and  is  mild  in  character 
throughout;  it  is  not  an  extension  along 
the  Euslaoliian  tube,  but  ia  an  afl'ection 
of  tlie  nuicous  cavities  of  the  car  com- 
plicating diphtheria:  one  of  the  symp- 
toms of  a  general  infection.  Lommel 
(Archives  of  Otol.,  Apr.,  '!)7). 


DIPHTHERIA.    COJIPLICATIONS  AND  SEQUELS. 


509 


In  some  cases  the  car  affection  is  of 
the  severest  type  and  there  is  consider- 
able destruction  of  the  drum-membrane. 
It  may  even  result  in  gangrene.  Pneu- 
monia, as  already  noted,  is  the  most  fre- 
quent and  dangerous  complication.  It  is 
most  common  in  laryngeal  diphtheria, 
but  may  follow  any  form  of  the  disease. 
It  is  attributed  to  the  action  of  the  pyo- 
genic cocci,  especially  the  streptococci, 
though  Stephens  and  Kanthack,  Wright, 
More,  and  others  have  demonstrated  the 
presence  of  the  diphtheria  bacillus  in  the 
lungs. 

During  a  period  of  two  and  one-half 
years  there  were  treated  at  the  South 
Department  of  the  Boston  City  Hospital 
157  patients  who  had  measles  and  diph- 
theria. Of  these,  54,  or  34  per  cent., 
died.  (The  death-rate  in  the  uncompli- 
cated diphtheria  patients  for  practically 
this  same  period  was  less  than  13  per 
cent.) 

From  these  cases  one  must  conclude 
that  the  existence  of  diphtheria  or  the 
possibility  of  its  onset  should  be  con- 
sidered in  every  case  of  measles,  for  the 
congestion  of  the  mucous  membrane  of 
the  tonsils  and  air-passages  caused  by 
the  measles  process  renders  it  especially 
vulnerable  and  an  unusually  good  field 
for  the  growth  of  the  bacilli  of  diph- 
theria. Nasal  or  laryngeal  obstruction 
arising  during  an  attack  of  measles  al- 
most certainly  means  diphtheria.  If  the 
initial  fever  of  measles  disappears,  and 
there  is  later  a  sudden  rise  of  tempera- 
ture, or  if  the  cough  of  measles  becomes 
"brassy"  in  quality  or  paroxysmal  in 
character  and  is  accompanied  by  an 
elevated  temperature,  the  possibility  of 
diphtheria  must  be  considered.  If  the 
initial  fever  persists  and  aphonia  devel- 
ops, diphtheria  is  probably  the  cause. 
Uncomplicated  measles  in  very  excep- 
tional cases  may  produce  aphonia,  but 
aphonia  with  or  without  a  rise  of  tem- 
perature usually  means  diphtheria,  and 
aphonia  with  a  rise  of  temperature  al- 
ways means  diphtheria.  Uncomplicated 
measles  is  usually  accompanied  by  a 
more  or  less  abundant  serous  nasal  dis- 


charge; but  if  this  discharge  become.s 
purulent  or  muco-purulent  in  character, 
or  if  there  is  partial  or  complete  nasal 
obstruction  accompanied  by  a  glairy  dis- 
charge, diphtheria  should  be  suspected 
and  cultures  taken.  But  if  the  patient's 
general  condition  in  addition  to  the 
above  symptoms  suggests  diphtheria, 
antitoxin  should  be  given  at  once  with- 
out awaiting  the  results  of  cultures.  In 
all  obscure  cases  the  patient  should  be 
given  the  benefit  of  the  doubt — and  anti- 
toxin. 

If  an  epidemic  of  measles   occurs   in 
an  institution  in  which  large  numbers 
of  children  are  cared  for,  each  child  as 
it  develops  measles  should  be  given  an 
immunizing  dose   of   antitoxin,   and   all 
inmates    of    the    institution    should    be 
carefully  watched  for  the  earliest  symp- 
toms of  either  disease.     D.  N.  Blakely 
and  F.   6.  Burrows    (Boston  Med.  and 
Surg.  Jour.,  July  25,  1901). 
The  affection  takes  the  form  of  bron- 
cho-pneumonia  and   is   commonly   met 
with  in  the  lower  lobes,  but  may  be  seen 
in  any  part  of  the  lungs.    The  areas  are 
scattered  and  separate  or  may  merge  into 
one  another  till  considerable  portions  of 
both  lungs  are  consolidated.    This  com- 
plication usually  develops  at  the  height 
of  the  disease,  but  may  occur  at  the  very 
beginning,  within  the  first  twenty-four 
hours,  or  may  arise  during  convalescence 
after  the  throat  is  clear.     Its  onset  is 
marked  by  increased  temperature;    dis- 
turbance of  the  pulse-respiration  ratio, 
— namely,  from  a  relation  of  1  to  4  to 
1  to  3;  greater  prostration  and  the  signs 
of  a  diffuse  bronchitis;   only  when  con- 
siderable areas  are  involved  do  we  ob- 
tain the  signs  of  consolidation. 

Pleurisy  is  rarely  met  vnth.  Em- 
pyema may  develop,  especially  in  septic 
cases.  Emphysema  is  frequently  seen 
in  laryngeal  cases;  it  may  be  interstitial 
and  may  extend  to  the  cellular  tissues 
of  the  neck,  but  is  commonly  vesicular. 
The  heart  is  more  seriously  affected  in 
diphtheria  than  in  any  other  of  the  acute 


610 


DIPHTHERIA.     COMPLICATIONS  AND  SEQUEL-E. 


infectious  diseases,  and  many  of  the  fatal 
cases  are  due  to  rapid  or  sudden  heart 
failure.  It  follows  tonsillar  or  pharyn- 
geal diphtheria  frequently,  and  is  rare 
after  other  forms.  Goodall,  in  a  recent 
study  of  these  cases,  gives  three  types  of 
the  affection: — 

1.  Heart-failure  while  the  exudate  is 
stni  present  in  the  throat  and  before 
other  symptoms  of  paralysis  present 
themselves.  It  is  then  due  to  the  direct 
action  of  the  diphtheria  toxins  upon  the 
nerve-mechanism  of  the  heart. 

2.  Heart-failure  after  the  disappear- 
ance of  membrane,  but  during  the  time 
of  other  symptoms  of  paralysis,  when  it 
may  be  due  either  to  disturbed  innerva- 
tion or  to  fatty  changes  in  the  heart- 
muscle,  such  as  are  met  with  in  other 
fevers. 

3.  Heart-failure  during  convalescence, 
some  time  after  the  disappearance  of 
membrane;  it  is  then  probably  caused 
by  degeneration  of  the  heart-muscle  or 
of  the  pneumogastric  nerve   (neuritis). 

Careful  autopsies  made  of  twenty-two 
cases  in  wliieh  death  was  due  to  some 
cardiac  complication.     In  eight  of  these 
cases    the    vagus,    stained    by    Marchi's 
method,  showed  evidence  of  degeneration. 
The    cells    in    the    nucleus    showed    no 
change,   even   when   there   was   marked 
degeneration  of  the  fibres  of  the  nerve. 
The  myocardium  in  these  cases  was  not 
systematically  examined,  but  the  weight 
of  the  heart  was  found  to  be  almost  con- 
stantly increased.     If  four  weeks  have 
elapsed   without  any  indication   of  car- 
diac trouble,  there  is  little  likelihood  of 
its  appearance  at  a  subsequent  period  of 
convalescence.      J.    J.    Thomas    (Boston 
City  IIosp.  Med.  and  Surg.  Reports,  '98). 
Whether  occurring  early  or  late  in  the 
disease,  the  symptoms  of  involvement  of 
the  heart  are,  in  general,  the  same:   the 
pulse  becomes  either  more  rapid  or  more 
often  slower;   it  may  be  intermittent  or 
irregular;  in  any  case  it  is  much  weaker. 
The  patients  are  greatly  prostrated,  may 


refuse  food,  and  may  vomit  repeatedly. 
The  surface  of  the  face  and  extremities 
may  be  pale  and  cold,  or  there  may  be 
dyspnoea  without  cyanosis.  There  may 
be  some  precordial  distress.  After  con- 
tinuing in  this  condition  for  hours  or 
daj's  the  patients  may  rally,  the  heart 
gradually  resumes  its  normal  action,  the 
sj'mptoms  disappear,  and  recovery  ensues. 
More  often  the  alarming  symptoms  grow 
worse  and  the  patients  succumb  to  the 
cardiac  weakness.  Death  may  be  caused 
by  sudden  syncope  induced  by  slight  ex- 
ertion or  excitement.  In  some  of  the 
cases  the  patients  are  regarded  as  thor- 
oughly convalescent  and  may  be  up  and 
about,  when  sudden  and  unforeseen  pa- 
ralysis of  the  heart  results  in  instant 
death.  The  cardiac  affection,  while  most 
often  seen  after  severe  diphtheria,  may 
be  a  sequel  of  the  mildest  cases.  Htem- 
orrhages  into  the  skin  or  from  mucous 
membranes  may  be  met  with  during  the 
height  of  the  disease.  They  are  most 
frequent  from  the  nose  and  may  be  so 
severe  as  to  require  plugging  of  the  pos- 
terior nares.  They  may  occur  from  other 
mucous  membranes:  the  stomach,  intes- 
tines, or  rarely  the  bladder.  In  the  skin 
the  hffimorrhage  may  give  rise  to  pete- 
chiiB  or  may  infiltrate  considerable  areas. 
The  petechice  are  most  often  seen  upon 
the  abdomen  and  lower  extremities,  but 
may  occur  upon  any  part  of  the  body. 
They  are  caused  by  changes  in  either  the 
blood  or  the  vessels  or  both,  and  are 
usually  seen  in  the  severer  types  of  tox- 
temia.  The  hocmorrhages  are  in  some 
cases  sulTicicnt  to  seriously  exhaust  the 
patient  and  may  even  cause  death. 

A  study  of  040  cases  emphasizes  the 
great  fretnicncy  of  heart  murmurs  and 
of  irregularity  of  the  pulse.  The  prog- 
nosis docs  not  depend  on  the  mere  pres- 
ence of  these  signs,  but  upon  the  severity 
of  the  infection,  the  length  of  time 
without  treatment,  the  rate  and  degree 


DIPHTHERIA.     COMPLICATIONS  AND  SEQUEL.,E. 


511 


of  irregularity  of  tlie  pulse,  and  tlie  pres- 
ence of  the  graver  signs  of  cardiac 
disturbance.  Moderate  disturbance  of 
tlie  heart  is  very  common;  severe  com- 
plications are  infrequent. 

Frequent  examinations  of  the  heart 
are  necess»ry  to  really  determine  its 
condition,  because  of  the  marked  changes 
in  rhytlim  from  one  hour  to  the  next. 
Examination  of  the  heart  and  pulse 
in  the  second  and  third  week  of  the  ill- 
ness are  necessary,  that  being  the  time 
when  severe  heart  complications  most 
frequently  occur. 

Broncho-pneumonia    is    a    more    fre- 
quent fatal   complication   of   diphtheria 
than  heart  disease;    sudden  death  from 
heart  disease  is  very  rare  when  patients 
are   kept   in    bed   for   a    proper   period. 
Prolonged  rest  in  bed  is  necessary  in  all 
severe  cases;   it  is  not  necessary  to  keep 
all   patients   in   bed   who   have   cardiac 
murnmrs  and  a  pulse  which  is  somewhat 
inegular    and    increased   in    rate.      One 
should  be  governed  by  the  stage  of  the 
illness  and  the  patient's  general  condi- 
tion.    If  no   serious   heart  ti-ouble  has 
developed  within  four  weeks  the  patients 
are  usually  safe  from  this  complication. 
Heart  murmurs  and  inegularity  are  of 
long  duration  in  many  cases,  and  make 
it  necessary  to  watch  the  condition  of 
the  heart  long  after  convalescence  in  all 
severe  cases.     F.  W.  White  and  H.  H. 
Smith    (Boston   Med.    and    Surg.    Jour., 
Oct.  20,  1904). 
Thrombosis  and  embolism  are  among 
the  rarer  complications  of   diphtheria. 
They  may  affect  the  extremities,  giving 
rise  to  the  usual  symptoms:  sudden  pain, 
numbness,  and  coldness  of  the  limbs,  fol- 
lowed  by  paralysis,   redema,   and   even 
gangrene.    Some  of  the  cases  of  cardiac 
paralysis  may  be  caused  by  thrombosis 
or  embolism  of  the  vessels  of  the  heart. 
Affecting  the  cerebral  arteries,  throm- 
bosis, embolism,  or  hajmorrhage  may  give 
rise  to  hemiplegia. 

In  very  rare  cases  the  stomach  may  be 
involved  in  the  diphtheritic  process;  but, 
apart  from  such  involvement,  gastric 
symptoms  are  common.    Persistent  vom- 


iting is  a  frequent  and  grave  occurrence 
in  severe  cases.  It  may  be  due  to  the 
fever  and  toxaemia,  or  to  nephritis  or  to 
heart-failure. 

Diarrhoea  is  often  met  with  during  the 
height  of  the  disease,  and  may  persist 
for  some  time  after  the  diphtheria  itself 
is  improved.  It  may  be  due  to  entero- 
colitis or  may  be  dependent  upon  the 
constitutional  condition,  especially  in  the 
septic  cases.  The  local  lesions  are  not 
severe  and  have  no  direct  relation  to  the 
diphtheritic  process.  As  already  noted, 
haemorrhages  may  occur  from  either 
stomach  or  intestine  in  rare  cases. 

The  kidneys  are  more  or  less  affected 
in  all  severe  cases  of  diphtheria.  The 
lesion  may  be  an  acute  degeneration, 
marked  by  more  or  less  albumin  in  the 
urine,  or  acute  exudative  nephritis  with 
albumin  and  casts,  but  without  dropsy 
or  ura?mic  symptoms.  Very  rarely  an 
acute  diffuse  nephritis  with  diminished 
urine  containing  albumin  and  casts,  or 
suppression  of  the  urine,  drops)',  and 
uraemia  may  be  seen. 

The  albuminuria  usually  comes  on 
during  the  height  of  the  disease,  con- 
tinues for  a  time,  and  disappears  rapidly 
with  improvement  in  the  local  symptoms. 
Only  in  the  rare  cases  in  which  acute  dif- 
fuse nephritis  develops  are  the  renal  com- 
plications likely  to  persist.  Marked  al- 
buminuria is  always  an  evidence  of  a 
grave  infection,  while  not  of  itself  a 
serious  complication.  It  is  most  com- 
mon in  the  septic  cases,  and  belongs  dis- 
tinctly to  pharyngeal,  or  tonsillar,  diph- 
theria. In  very  rare  cases  there  may  be 
hosmorrhagcs  from  the  kidneys. 

Mention  has  already  been  made  of  the 
fact  that,  pathologically  and  experiment- 
ally, the  most  characteristic  lesion  of 
diphtheria  is  that  affecting  the  nervous 
system  and  giving  rise  to  paralysis  of 
various  groups  of  muscles.     Clinically, 


51Z 


DIPHTHERIA.    COMPLICATIONS  AXD  SEQUEL.-E. 


paralysis  is  infrequent,  but  in  its  distri- 
bution, tj-pe,  and  course,  none  the  less 
characteristic.  In  2-14:8  cases  collected 
by  Sanne  paralysis  was  noted  in  11  per 
cent.;  in  a  series  of  1000  cases  reported 
by  Lennox  Browne  in  14  per  cent.;  in 
1071  cases  belonging  to  preantitoxin 
days  studied  by  Goodall,  after  deducting 
a  mortality  of  33. S  per  cent.,  he  says  he 
observed  paralysis  in  125  of  the  709  sur- 
vivors,— 17.6  per  cent,  of  the  latter  num- 
ber, or  11.7  per  cent,  of  the  whole  num- 
ber; in  33S4  cases,  treated  by  antitoxin, 
comprised  in  the  Report  of  American 
Pediatric  Society,  paralysis  was  met  with 
in  32S  cases, — 9.7  per  cent,  of  the  whole 
number.  Of  the  2934  cases  that  recov- 
ered, 276 — or  9.4  per  cent. — showed  pa- 
ralysis, while,  of  the  450  fatal  cases, 
paralysis  was  observed  in  52,  or  11.4  per 
cent.  Simply  taking  the  totals  of  these 
figures  without  relation  to  the  question 
of  treatment,  we  have  852  cases  of  pa- 
ralysis occurring  among  7903  cases,  or  in 
10.7  per  cent. 

Secondary  paralysis  occurs  very  fre- 
quently. Out  of  1316  cases  admitted 
into  Park  Hospital,  275  showed  distinct 
diphtheritic  paralyses  and  pareses.  One 
case  of  diphtheria  out  of  every  five  pa- 
tients thus  suffered  from  some  paralytic 
trouble,  which  was  most  frequent  in 
eases  between  three  and  eight  years. 
There  were  80  deaths  among  the  cases 
that  suffered  from  paralysis,  and  64 
of  these  had  cardiac  paralysis.  The 
average  day  upon  which  the  cardiac 
paralysis  appeared  was  the  seventh. 
Average  duration  of  life  after  cardiac 
paralysis  in  cases  which  died  was  four 
days.  There  were  21  cases  of  diaphrag- 
matic paresis  and  paralysis,  of  which  11 
terminated  fatally  and  10  recovered. 
There  were  110  cases  where  the  palate 
alone  was  affected,  and  50  cases  in 
which  the  palate  was  paralyzed  in  con- 
nection with  other  muscles,  the  largest 
number  being  associated  with  the  exter- 
nal rectus,  and  next  to  that  the  dia- 
phragm. Meyers  (Lancet,  Sept.  22, 1000). 


Paralysis  usually  complicates  the  se- 
verer cases  of  pharj-ngeal  diphtheria,  but 
may  be  seen  after  milder  forms,  and  it 
has  even  been  reported  as  following  affec- 
tions of  the  throat  so  mild  as  to  have 
attracted  little  or  no  attention. 

The  time  of  the  onset  of  paralytic 
s}Tnptoms  varies  greatly  in  different 
cases.  It  may  occur  at  the  height  of  the 
disease  in  the  latter  days  of  the  first  week 
or  the  beginning  of  the  second,  but  is 
usually  seen  some  time  after  the  throat 
is  altogether  clear  during  the  third  or 
fourth  week  of  the  disease,  and  may 
occur  as  late  as  the  tenth  week  after  the 
onset.  In  the  cases  reported  by  Goodall 
the  paralysis  was  observed  from  the  sev- 
enth to  the  forty-ninth  day. 

In  171  cases  of  diphtheritic  paralysis 
collected  by  Eoss  the  following  distribu- 
tion was  observed:  Palate  affected  in 
128;  eyes  in  77,  in  54  of  which  the 
muscles  of  accomodation  suffered;  lower 
extremities  in  113;  upper  extremities  in 
60;  trunk  or  neck  in  58;  muscles  of 
respiration,  33.  Of  the  328  cases  reported 
to  the  American  Pediatric  Society  the 
distribution  was  specified  in  187. 

Of  this  number  in  120  involved  the 
throat  (palate,  pharynx,  and  larynx);  in 
14  the  extremities;  in  11  the  eyes;  in 
32  the  heart;  in  1  the  muscles  of  respira- 
tion; in  1  the  sterno-mostoid;  and  in  8 
the  paralysis  was  general. 

Paralysis  caused  by  iiiultiple  neuritis, 
in  the  majority  of  cases,  nuist  be  at- 
tril)\ited  to  the  toxic  effects  of  the  prod- 
ucts of  the  Klebs-Locdier  bacilli.  It 
occurs  in  from  10  to  25  per  cent,  of  cases. 
The  treatment  of  the  original  disease, 
by  antitoxin,  or  otherwise,  does  not  ap- 
pear to  have  any  influence  upon  the 
subsequent  development.  Fraiieis  TTulicr 
(Pediatrics,  June   1,  '09). 

The  nervoiis  system  studied  in  nine 
f,'iiiiioa-pigs  which  had  been  injected  with 
illlcrcd     diphtheria    broth    in    varying 


DIPHTHERIA.     COMPLICATIONS  AND  SEQUELS. 


513 


quantities,  and  also  in  a  number  of 
children  who  died  of  the  disease.  Per- 
sonal conclusion  reached  that  the  paral- 
j'ses  may  be  eitlier  central  or  peripheral 
in  origin.  In  tlie  former  case,  the  ante- 
rior liorn  cell  first  becomes  the  seat  of 
degenerative  changes,  as  evidenced  by 
abnormal  staining  reactions,  while  the 
nerve-fibre  is  still  normal  in  appearance. 
A  secondary  descending  atrophy  of  the 
nerve,  however,  follows  upon  tlie  disease 
of  the  central  cell.  In  the  latter,  or 
peripheral  tj-pe,  of  which  the  common 
palate  paralysis  is  an  example,  the  mus- 
cles paralyzed  are  those  in  connection 
with  peripheral  nerve-fibres  which  come 
into  close  relation  with  the  seat  of 
toxin-formation  in  the  throat  and  naso- 
pharynx. The  central  paralyses  are 
toxoemic  in  origin;  the  peripheral  are 
due  to  local  and  direct  irritation.  Foul- 
erton  and  Thomson  (Edinburgh  Med. 
Jour.,  Jan.,  1002). 

The  frequency  of  paralysis  is  in  direct 
proportion  to  the  severity  of  the  general 
infection,  although  a  severe  palsy  may 
follow  a  mild  type  of  diphtheritic  intox- 
ication.    The  location  of  the  membrane 
is    of    considerable    importance    as    an 
etiological     factor,     diphtheria     of     the 
posterior   nares    especially    predisposing 
to  both  local  and  widespread  palsy.    Tlie 
proportion  of  cases  followed  by  paralysis 
is  variously  estimated  at  from  10  to  30 
per  cent.       Peter    (Jledical   Xews,  Feb. 
14,  1903J. 
In  the  series  published  by  Goodall, 
the   palate   alone   was  first   affected   in 
66  per  cent,  of  the  125  cases,  and  in 
combination  with  other  muscles  it  was 
involved  in  12  per  cent.  more.     In  a 
little  over  one-half  of  the  cases  the  pa- 
ralysis was  limited,  and  in  12  per  cent,  it 
was  generalized.     The  affection  of  the 
throat  is  therefore  much  the  most  com- 
mon.   It  may  occur  alone  or  be  followed 
by  paralysis  of  other  parts:  the  eye,  the 
extremities,  the  trunk,  or  neck.    In  some 
cases  it  precedes  the  cardiac  paralysis, 
but,  as  a  rule,  this  most  grave  form  of 
diphtheritic     paralysis     appears    unan- 
nounced.    Absence  of  the  patellar  re- 

2- 


fle.xes  is  observed  in  most  cases  of  diph- 
theritic paralysis,  even  when  there  is  no 
loss  of  power  or  sensation  in  the  lower 
extremities,  and  is  regarded  as  a  sign  of 
the  probable  appearance  of  paralysis  else- 
where. 

In  most  of  the  throat  cases  the  uvula 
and  soft  palate  alone  are  involved.  Nasal 
voice  and  regurgitation  of  fluid  through 
the  nose  evidence  the  loss  of  power  in 
these  parts,  and  upon  inspection  we  see 
the  uvula  hanging  straight  downward, 
relaxed,  and  motionless  upon  the  back 
of  the  tongue.  Sensation  as  well  as  mo- . 
tion  is  gone,  and  there  will  be  no  re- 
sponse to  irritation.  If  the  pharyngeal 
muscles  are  involved,  there  is  difficulty 
in  swallowing,  and,  if  the  larynx  suffers, 
there  will  be  aphonia  and  severe  cough- 
ing upon  attempt  at  swallowing  anything 
by  reason  of  the  entrance  of  food  or 
drink  into  the  imperfectly  closed  organ. 
The  latter  class  of  cases  is  very  likely  to 
prove  fatal  through  the  development  of 
pneumonia  from  the  inspiration  of  for- 
eign material.  In  the  extremities — arms, 
legs,  or  neck — we  see  more  or  less  com- 
plete loss  of  power  and  sensation.  The 
paralysis  may  not,  however,  be  general- 
ized in  these  parts,  but  appears  at  times 
to  attack  only  the  muscles  supplied  by  a 
particular  nerve-trunk,  or  even  a  branch 
of  a  main  nerve.  The  paralysis  may  be 
so  extensive  as  to  render  the  patient  per- 
fectly helpless.  When  the  trunk  is  in- 
volved, the  gravest  danger  arises  from 
implication  of  the  muscles  of  respira- 
tion. Usually  the  diaphragm  is  first 
involved,  but  the  intercostals  may  suf- 
fer. If  the  diaphragm  is  paralyzed,  the 
respiration  is  entirely  thoracic;  if  the 
intercostals,  then  the  diaphragm  alone 
must  do  the  work.  Either  affection  is 
characterized  by  attacks  of  urgent 
dyspnoea,  with  cyanosis.  The  wind  be- 
ing perfectly  clear  and  respiration  main- 


514 


DIPHTHERIA.    COMPLICATIONS  AND  SEQUEL-E. 


tained  only  by  the  greatest  effort  on  the 
part  of  the  victim,  the  distress  is  often 
terrible.  The  danger  of  suffocation  is 
imminent.  Such  an  attack  may  pass 
off  and  there  be  no  return;  but  more 
often  they  recur  in  a  short  time.  The 
patient  may  remain  in  this  condition  for 
several  days,  before  death  finally  ends 
the  struggle. 

Few  of  these  cases  recover:  only  eight 
in  thirty-three  of  Boss's  series.  At  any 
time  there  may  be  involvement  of  the 
pneumogastric  nerves  as  well  as  the 
phrenic,  the  new  invasion  declaring  itself 
by  attacks  of  abdominal  pain,  vomiting, 
and  feeble  and  slow  or  irregular  pulse. 
At  other  times  the  heart  may  continue 
to  act  quite  normally  despite  the  respira- 
tory distress. 

We  have  already  spoken  of  the  purely 
cardiac  type  of  this  affection,  for  it  is 
impossible  on  clinical  grounds  to  sepa- 
rate from  one  another  the  cardiac  failure 
due  to  changes  in  the  myocardium  from 
that  produced  by  involvement  of  the 
pneumogastric  or  other  cardiac  nerves 
by  the  neuritis.  Furthermore,  the  two 
conditions  are  often  associated.  It  may 
be  well  again  to  point  out  the  suddenness 
with  which  cardiac  paralysis  may  occur 
by  quoting  from  the  Eeport  of  the  Amer- 
ican Pediatric  Society  the  follomng  para- 
graph: "Observations  of  some  of  the 
individual  cases  are  interesting,  particu- 
larly those  of  cardiac  paralysis.  It  is 
twice  stated  that  the  child  had  gotten 
up  and  walked  out  of  the  house,  where 
it  was  found  dead. 

"Twice  death  occurred  after  sitting  up 
suddenly;  once,  on  jumping  from  one 
bed  to  another.  One  patient  of  twenty 
years  got  up  contrary  to  orders  and  died 
soon  afterward.  Another  patient  was 
apparently  well,  until  he  indulged  in  a 
large  quantity  of  cake  and  candy,  soon 


after  which  cardiac  symptoms  developed 
and  he  died  shortly." 

^Vhen  the  eyes  are  affected  there  is 
indistinctness  of  vision  usually  resulting 
in  inability  to  read,  caused  by  paralysis 
of  the  muscles  of  accommodation.  The 
pupils  may  be  dilated  or  sluggish  in  ac- 
tion from  involvement  of  the  sphincter 
iridis.  Strabismus  or  ptosis  from  pa- 
ralysis of  the  extrinsic  muscles  of  the 
eyes  are  rarely  seen. 

One  hundred  and  fifty  cases  of  post- 
diphtheritic paralysis  of  accommodation 
obsen-ed.  Paralysis  set  in  two  to  three 
weeks  after  the  beginning  of  the  diph- 
theria in  the  throat,  lasted  about  four 
weeks,  and  always  disappeared  sponta- 
neously. The  degree  of  paralysis  was  not 
always  proportionate  to  the  intensity  of 
the  disease,  and  ranged  from  -|-  1  D. 
to  -)-  6  D.  for  five  letters  at  9  inches. 
All  the  cases  except  six  presented  an 
hj'peruietropia  of  1  to  3  D.  This  was 
explained  on  the  ground  of  childhood 
hypermetropia. 

The  onset  is  sudden,  the  recovery  grad- 
ual. Rarely  is  there  paralysis  of  the 
sphincter  of  the  pupil.  Moll  has  ob- 
served it  only  four  times. 

Accompanying  paralyses  were  as  fol- 
low: Sixteen  times  paralysis  was 
double  and  three  times  unilateral  of  the 
sixth  pair.  Diplopia  must  be  tested  for 
with  colored  glass.  Once  a  unilateral 
ptosis.  Once  insufficiency  of  the  right 
internal  rectus  with  asthenopia  in  a 
chlorotic  subject.  In  the  majority  of  the 
cases  paralysis  of  the  velum  palati  and 
the  pharynx.  The  fundus  was  always 
normal.  H.  Coppey  (Arch.  d'Ophtal., 
No.  2,  p.  117,  '97). 

Diphtheria  is  rare  in  nursing  infants, 
especially  soon  after  birth ;  should  there 
be  distinct  contagion,  the  infant  will 
contract  diphtheria  easily;  the  mortal- 
ity is  much  higher  among  nursing  in- 
fants, because  of  their  decreased  resist- 
ance and  the  diflieulty  in  forming  the 
diagnosis;  the  l)acilli  enter  by  the 
mouth;  nasal  diplil-lieria  is  secondary 
from  the  pharynx,  while  laryngeal  and 
pulmonary  complications  are  very  rare. 
The  treatment  consists  of  prophylactic 


DIPHTHERIA.    DIFFERENTIAL  DIAGNOSIS. 


515 


injections  of  antitoxin  in  times  of  epi- 
demic, and  larger  injections  later,  re- 
peated when  necessar)',  with  some  local 
treatment;  and,  finally,  in  spite  of 
the  antitoxin  treatment,  the  mortality 
reached  00  per  cent.  Cristeanu  and 
Bruckner  (Archives  de  MC-d.  des  Enfants, 
Nov.,  1901). 

The  frequency  of  paralysis  is  in  direct 
proportion  to  the  severity  of  the  general 
infection,  although  a  severe  palsy  may 
follow   a   mild  type   of   diphtheritic   in- 
toxication.    The  location   of  the   mem- 
brane is  of  considerable  importance  as 
an  etiological  factor,  diphtheria  of  the 
posterior   nares   especially   predisposing 
to    both    local    and    widespread    palsy. 
The    proportion    of    cases    followed    by 
paralysis  is  variously  estimated  at  from 
10  to  30  per  cent.    Peter  (Medical  News, 
Feb.  14,  1903). 
Facial  and  glossal  paralyses  have  both 
been  reported,  and  in  some  of  the  sever- 
est types  of  general  paralysis  the  sphinc- 
ters of  the  bladder  and  rectum  are  said 
to  have  been  involved. 

If  the  case  does  not  result  fatally  either 
directly  from  the  paralysis  or  from  the 
diphtheria  itself  or  other  complications, 
the  paralysis  will  surely  recover.  In 
none  of  the  cases  observed  by  Goodall 
was  the  paralysis  permanent.  The  time 
required  depends  upon  the  degree  and 
extent  of  the  paralysis.  Those  in  which 
the  throat  alone  is  affected  usually  re- 
cover completely  within  a  week  or  two. 
Cases  of  multiple  or  generalized  paraly- 
sis may  require  three  or  four  months  to 
regain  normal  power. 

Differential  Diagnosis. — The  bacterio- 
logical investigations  inspired  by  the 
identification  of  the  Klebs-Loeffler  ba- 
cillus have  greatly  simplified  the  ques- 
tion of  the  relationship  of  the  various 
pseudomembranous  inflammations. 

The  fact  of  not  finding  diphtheria  ba- 
cillus in  cases  of  clinical  diphtheria 
always  due  to  some  error  in  technique. 
Important  practical  point:  On  the  sur- 
face of  membrane  bacilli  frequently  die; 


therefore,  if  the  culture  be  taken  directly 
from  the  surface,  in  majority  of  cases  a 
negative  result  will  be  obtained.  If  the 
wire  be  passed  through  the  membrane  or 
along  its  edges  a  positive  result  is  almost 
invariably  reached.  McCollom  (Boston 
Med.  and  Surg.  Jour.,  May  9,  '95). 

Loelller  bacillus  present  in  much  more 
than  73  per  cent,  of  real  clinical  diph- 
therias. F.  G.  Novy  (Med.  News,  July 
13,  '95). 

We  now  know  definitely  that  there  are 
but  two  great  types:  the  one  termed 
pseudodiphtjieria,  produced  by  strepto- 
cocci or  staphylococci  and  belonging  to 
the  acute  infectious  diseases, — measles  or 
scarlet  fever, — and  true  diphtheria,  pro- 
duced by  the  specific  bacillus,  and  usu- 
ally a  primary  and  independent  affection. 
On  the  other  hand,  these  investigations 
have  added  complexity  to  the  problem  of 
diagnosis  of  throat  affections  by  showing 
the  presence  of  the  specific  bacilli  of 
diphtheria  in  many  cases  of  sore  throat 
free  from  membrane  and  previously 
passed  over  as  simply  "catarrhal"  sore 
throat,  and  also  in  many  of  the  cases  of 
a  fairly  definite  clinical  type,  formerly 
classified  as  follicular  tonsillitis. 

There  are  some  angina;  which,  al- 
though resembling  diphtheria,  are  not 
caused  by  Loefllers  bacillus.  A  typical 
lacunar  tonsillitis  may  appear  absolutely 
indistinguishable  from  ordinary  follicu- 
lar tonsillitis,  and  sometimes  the  diph- 
theritic process  may  start  in  the  lowest 
parts  of  the  tonsils  and  so  escape  de- 
tection. It  is  well  to  isolate  cases  of 
lacunar  angina,  and  during  an  epidemic 
of  diphtheria  they  should  be  looked  upon 
with  much  suspicion.  It  is  better  that 
diplitheria  should  be  diagnosed  too  often 
than  that  cases  of  true  diphtheria  should 
be  overlooked.  Vierordt  (Berliner  klin. 
Woch.,  Feb.  22,  '97). 

In  the  shifting  of  the  lines  that  has 
followed  these  revelations  a  considerable 
degree  of  mental  confusion  has  been  en- 
gendered and  an  uncertainty  fostered 
that  has  led  many  to  lose  all  faith  in  the 


516 


DIPHTHERIA.    DIFFERENTIAL  DIAC4N0SIS. 


results  of  clinical  observations.  If  it  is 
necessary  to  rearrange  the  lines  of  classi- 
fication somewhat,  it  is  not  required  that 
we  abandon  all  our  former  conceptions 
or  no  longer  trust  to  careful  observation. 
In  the  great  majority  of  cases  thorough 
examination  and  careful  consideration 
of  all  the  factors  concerned  will  enable 
one  to  reach  a  positive  diagnosis  without 
awaiting  the  results  of  a  bacteriological 
examination,  although  the  latter  should 
always  be  employed  if  possible.  For  the 
sake  of  clearness  we  shall  follow  the 
order  adopted  in  the  description  of  clin- 
ical s}Tnptoms. 

Nasal  Cases. — The  only  cases  that 
are  difficult  of  diagnosis  are  those  of 
primary  nasal  diphtheria.  The  thin,  irri- 
tating, muco-purulent  discharge,  often 
brownish  from  the  presence  of  blood,  is 
quite  different  from  the  abundant,  ropy 
mucus  seen  in  simple  catarrhal  inflam- 
mation. Excoriation  of  the  nares  and 
eczema  of  the  upper  lip  produced  by  the 
discharge  are  suggestive  of  diphtheria. 
Careful  inspection  may  show  the  pres- 
ence of  more  or  less  white  or  grayish- 
white  exudate  on  the  mucous  membrane, 
in  which  case  the  diagnosis  of  diphtheria 
may  be  safely  advanced.  Furthermore, 
the  diphtheritic  cases  are  accompanied 
by  some  slight  rise  of  temperature, 
anorexia,  and  a  distinct  degree  of  con- 
stitutional depression  not  seen  in  cases 
of  simple  inflammation.  Finally,  these 
cases  are  much  more  often  seen  in  insti- 
tutions where  the  children  are  more  or 
less  constantly  exposed  to  diphtheritic 
infection  than  in  private  or  dispensary 
practice. 

Pharyngeal,  on  Tonsillar,  Cases. 
— These  often  present  difficulties  in  di- 
agnosis, but  a  full  consideration  of  all 
the  factors  in  any  case  will  usually  lead 
to  a  correct  judgment.  The  most  difli- 
cult  cases  are  the  milder  ones,  where 


there  is  little  or  no  membrane  and  the 
constitutional  sjTnptoms  are  slight.  The 
question  of  exposure  should  be  consid- 
ered in  every  case.  Children  gathered 
in  hospitals  or  asylums  or  attending 
schools  are  especially  exposed  to  diph- 
theritic infection,  and  in  them  any  form 
of  sore  throat  may  justly  be  looked  upon 
with  suspicion.  So  far  as  the  catarrhal 
form  of  diphtheria  is  concerned,  even 
with  a  history  of  exposure,  there  is 
no  way  of  making  a  diagnosis  of  diph- 
theria in  the  early  stages  except  by  bac- 
teriological cultures.  The  after-course 
of  some  of  these  cases — in  which  we  may 
see  invasion  of  the  larynx,  broncho-pneu- 
monia, nephritis,  or  paralj'sis — -may  show 
them  to  have  been  diphtheria,  when  no 
suspicion  has  previously  been  enter- 
tained. 

When  diphtheritic  membrane  is  pres- 
ent in  the  throat,  it  usually  presents  cer- 
tain definite  characters.  It  begins  as  a 
thin,  translucent  deposit  upon  one  or 
both  tonsils.  Gradually  or  rapidly  it 
becomes  thicker,  and  assumes  a  white, 
gray,  or  grayish-green,  brown,  or — in 
malignant  cases — black  color,  and  ex- 
tends peripherally  to  cover  a  larger  and 
larger  area.  It  is  firmly  attached  to  the 
mucous  membrane  or  underlying  tissues 
and  cannot  be  easily  rubbed  off.  If  re- 
moved by  force,  a  raw,  bleeding  surface 
is  left,  and  in  a  very  short  time  the  mem- 
brane is  reproduced  in  its  original  or 
even  a  greater  extent.  Beginning  upon 
the  tonsils,  the  membrane  rapidly  ex- 
tends to  other  parts:  the  lateral  walls 
of  the  pharynx,  the  fauces,  or  uvula. 
Upon  any  of  these  parts  the  membrane 
presents  the  same  characters  as  at  the 
original  site.  This  extension  of  the  mem- 
brane is  most  characteristic  of  diph- 
theria. The  only  cases  in  which  we  are 
likely  to  see  such  extension  of  a  pseudo- 
diphtheritic  membrane  are  the  throat  in-^ 


JJIPIITIIERIA.     DIFFEKENTIAL  DIAGNOSIS. 


517 


flammations  accompanying  other  infec- 
tious diseases,  measles,  small-pox,  and — 
most  of  all — scarle^  fever.  The  great 
majority  of  the  membranous  throat  af- 
fections seen  in  the  early  stages  of  these 
diseases  are  produced  by  the  action  of 
streptococci  or  staphylococci.  When  a 
similar  process  is  seen  as  a  late  complica- 
tion of  infectious  diseases,  it  is  more 
probably  true  diphtheria. 

The  early  temperature  in  diphtheria 
is  not  usually  high;  it  is,  in  fact,  gen- 
erally lower  than  in  pseudodiphtheria, 
with  an  equal  amount  of  membrane. 
A  high  temperature  in  the  beginning  is, 
therefore,  an  indication  that  the  case  is 
not  diphtheria.  On  the  other  hand, 
the  prostration  is  greater  in  diphtheria 
than  in  pseudodiphtheria.  The  pulse  is 
feebler;  the  patients  look  and  feel  sicker 
than  they  do  when  suffering  from 
pseudodiphtheria.  The  presence  of  a 
nasal  discharge  of  the  character  de- 
scribed as  belonging  to  nasal  diphtheria 
and  marked  swelling  and  tenderness  of 
the  cervical  lymph-nodes  help  to  dis- 
tinguish some  cases  in  the  early  stages. 
Later  we  look  for  the  development  of 
the  typical  complications  or  sequelae  of 
diphtheria:  invasion  of  the  larynx, 
broncho-pneumonia,  albuminuria,  or 
some  of  the  manifold  forms  of  paralysis. 
The  occurrence  of  any  of  these  processes 
is  usually  sufficient  to  make  the  diag- 
nosis certain,  although  it  is  not  impos- 
sible that  any  of  them  except  the  paraly- 
sis may  be  seen  in  cases  of  pseudodiph- 
theria. Paralysis  subsequent  to  throat 
inflammation  is  seen  only  in  diphtheria. 
Pseudodiphtheria  is,  in  the  great  ma- 
jority of  cases,  a  milder  disease  and  of 
shorter  course  than  diphtheria.  As  al- 
ready remarked,  the  primary  throat  in- 
flammation of  scarlet  fever  most  closely 
resembles  true  diphtheria.  In  fact,  in 
every  case  where  diphtheria  is  suspected, 


the  possibility  of  scarlet  fever  must  be 
borne  in  mind  and  examination  made 
for  the  eruption.  Oftentimes  it  will  be 
found  at  the  very  first  examination;  at 
any  rate,  a  brief  delay  will  suffice  to  de- 
termine the  question,  as  the  eruption  of 
scarlet  fever  so  quickly  follows  the  ini- 
tial symptoms.  It  may  even  happen  that 
the  throat  symptoms  of  measles  may 
simulate  diphtheria,  and  especially  if  the 
eruption  be  delayed  for  a  number  of 
days.  Here,  however,  there  is  rarely  any 
membrane  at  all,  and  the  presence  of 
conjunctivitis,  with  the  simple  mucous 
discharges  from  nose  and  throat,  should 
be  sufficient  to  prevent  mistake.  Fur- 
thermore, if  Koplik's  observation  of  the 
occurrence  of  an  eruption  of  peculiar 
bluish-white  specks  upon  a  reddish 
background  on  the  mucous  membrane 
of  the  mouth  previous  to  the  appearance 
of  the  regular  skin  exanthem  of  measles 
be  proved  correct,  it  should  furnish 
another  basis  for  differential  diagnosis. 
Laryngeal  Cases. — When  the  laryn- 
gitis appears  as  the  extension  of  a  pre- 
vious process  in  nose  or  throat,  except 
in  the  case  of  measles  or  scarlet  fever, 
we  can  safely  put  it  down  as  diphtheritic. 
The  pseudomembranous  throat  inflam- 
mations of  measles  and  scarlet  fever 
often  involve  the  larynx,  trachea,  and 
bronchi,  although  the  processes  are  not 
diphtheritic.  In  any  other  case  such 
extension  is  almost  conclusive  evidence 
that  we  have  to  do  with  diphtheria.  The 
greater  difficulty  is  prevented  by  the 
primary  cases  of  laryngitis  in  children. 
The  characteristic  feature  of  diphtheria 
of  the  larynx  is  its  progressive,  unre- 
mitting dyspna^a  with  aphonia.  The 
disease  steadily  advances  to  laryngeal 
stenosis  and  death  from  strangulation, 
unless  relieved  by  treatment.  Simple 
catarrhal,  or  non-diphtheritic,  pseudo- 
membranous   laryngitis,    on    the    other 


518 


DIPHTHERIA.    DIFFERENTIAL  DIAGNOSIS. 


hand,  usually  siioTs  frequent  and  de- 
cided remissions — its  crises  belonging 
to  the  night,  the  day  showing  decided 
remission  of  aU  the  symptoms.  As  in 
the  pharyngeal  cases,  early  high  tem- 
perature belongs  rather  to  the  pseudo- 
diphtheria.  If  laryngeal  examination  be 
possible  and  we  can  see  and  determine 
the  character  and  extent  of  the  mem- 
brane in  the  larynx,  we  ought  to  be  able 
to  reach  a  positive  diagnosis;  but,  un- 
fortunately, such  examination  is  not 
practicable  among  yoxmg  children,  who 
furnish  the  great  majority  of  the  cases 
of  acute  laryngitis.  Of  283  cases  of 
acute  laryngitis  subjected  to  bacterio- 
logical examination  by  the  New  York 
Board  of  Health,  229— or  SO  per  cent.— 
proved  to  be  true  diphtheria;  so  that  in 
the  city,  at  least,  the  diagnosis  in  any 
such  case  would  incline  to  diphtheria. 

Differential  Diagnosis. 


Diphtheria. 

1.  Exposure  to  infec- 
tion from  previous 
case  of  diphtheria. 

2.  Greatest  liability 
in  early  years:  first 
to  fifth  year. 

3.  Membrane  either 
seen  from  first  upon 
pharynx,  fauces,  or 
uvula,  as  well  as 
tonsils,  or  rapidly 
extends  to  these 
parts. 

4.  Membrane  firmly 
attached  to  underly- 
ing tissues,  and  not 
easily  rubbed  ofl. 

5.  If  membrane  be  re- 
moved, leaves  bleed- 
ing surface. 

6.  If  removed,  mem- 
brane is  very  rap- 
idly reproduced  in 
an  even  greater 
amount. 


PseudcKliphtheria. 

1.  No  such  exposure: 
arises  independently. 

2.  Occurs  at  any  age. 


3.  Membrane  limited 
to  tonsils. 


4.  Membrane  loosely 
attached  and  easily 
removed. 

5.  Membrane  may  be 
removed  without 
such  bleeding. 

0.  Reproduction  of 
membrane  not  so 
rapid   or   extensive. 


7.  Discharge  from 
nose,  thin,  irrita- 
ting, often  bloody, 
and  produces  eczema 
of  upper  lip. 

S.  Submaxillary  and 
cervical  lymph- 
nodes  swelled  and 
tender. 


9.  Membrane  may  be 
seen  upon  buccal 
mucous  membrane, 
tongue,  angles  ol 
the  mouth,  or  lips. 

10.  Onset  gradual ; 
temperature  low  at 
beginning. 

11.  Constitutional  de- 
pression is  more 
marked,  the  pulse 
weaker,  and  chil- 
dren more  pros- 
trated. 


12.  Course  longer  : 
usually  five  days  to 
a  week  before 
marked  improve- 
ment is  seen. 

13.  Albuminuria  com- 
mon and  severe  ne- 
phritis frequent. 

14.  Larynx  often  in- 
volved by  extension. 


15.  Paralysis  of  more 
or  less  extensive 
groups  of  muscles 
may  occur,  as  a 
complication  or  se- 
quel. 


7.  Nasal  discharge 
not  so  common,  and 
is  simple,  muco-pur- 
ulent. 

S.  Swelling  of  lymph- 
nodes  not  so  marked 
in  primary  cases;  is 
regularly  met  with, 
however,  in  throat 
inflammations  of 
scarlet  fever,  etc. 

9.  Not  seen  upon 
these  parts. 


10.  Onset  more  sud- 
den;  temperature 
higher. 

11.  Constitutional 
symptoms  usually 
in  proportion  to 
temperature;  more 
moderate.  Pulse 
rapid,  but  not  weak, 
and  depression  not 
so  marked. 

12.  Course  shorter,  ex- 
cept in  cases  com- 
plicating infectious 
diseases;  is  usually 
three  or  four  days. 

13.  Much  rarer. 


14.  Larynx  rarely  at- 
tacked secondarily, 
except  in  measles  or 
scarlet  fever. 

15.  No  such  paralysis 
seen. 


While  it  is  true  that,  as  many  authori- 
ties maintain,  in  95  per  cent,  of  the 
cases  which  an  expert  after  careful  con- 
sideration would  pronounce  diphtheria, 
cultures  will  show  the  presence  of  the 
specific  bacillus,  it  must  be  frankly  ad- 


DIPHTHERIA.    DIFFEKENTIAL  DIAGNOSIS. 


519 


mitted  that  there  are  many  ca.5es  in 
which  the  most  careM  observation  can- 
not determine  positively  the  question 
whether  a  given  case  is  true  diphtheria 
or  pseudodiphtheria.  Thus,  in  Scien- 
tific Bulletin  No.  1,  of  the  New  York 
Board  of  Health,  we  find  it  stated  that 
"Baginsky,  in  Berlin,  found  the  diph- 
theria bacillus  in  120  out  of  154  sus- 
pected cases;  Martin,  in  Paris,  in  126 
out  of  200;  Park,  in  New  York,  in  127 
out  of  244;  Janson,  in  Switzerland,  63 
out  of  100;  and  Morse,  of  Boston,  in 
239  out  of  400.  Thus,  from  20  to  50 
per  cent,  of  the  cases  sent  to  diphtheria 
hospitals  did  not  have  diphtheria."  If 
these  figures  approximate  the  truth,  it 
is  evident  that  we  cannot  trust  with 
safety  to  clinical  observations  to  de- 
termine the  specific  relation  of  cases  of 
throat  inflammation.  On  the  other 
hand,  the  routine  use  of  cultures  from 
all  cases  of  sore  throat  regularly  shows 
the  presence  of  the  diphtheria  bacillus 
in  a  considerable  number  of  cases  in 
which  there  were  few  or  none  of  the 
features  regarded  as  characteristic  of 
diplithcria,  and  in  which  there  was, 
therefore,  little  or  no  suspicions  of  the 
presence  of  the  specific  bacillus. 

While  so  far  as  the  individual  case  is 
concerned,  it  may  be  remarked  that  the 
cases  in  which  the  diagnosis  is  most  dif- 
ficult are  the  mild  cases,  those  least 
likely  to  be  attended  with  grave  conse- 
quences to  the  patient  himself,  the  fact 
should  also  be  recognized  that  these 
mild  cases  are  quite  as  dangerous  to 
others  as  severe  ones,  and  should,  for 
the  sake  of  the  community,  be  subjected 
to  strict  quarantine.  It  is,  therefore, 
essential  to  accurate  work  and  proper 
care,  as  well  as  proper  prophylaxis,  that 
cultures  should  be  made  from  all  cases 
of  sore  throat.  In  no  other  way  can  we 
stand  upon  solid  ground  with  relation  to 


treatment,  or  hope  to  eventually  gain 
control  of  the  wide-spread  and  dangerous 
infection. 

[Scientific  Bulletin,  No.  1,  Health  De- 
partment of  the  City  of  New  York,  is  the 
source  from  which  the  great  part  of  the 
material  of  this  section  is  drawn.  W.  P. 
NonTnitup  and  David  Bovaird.] 

Methods  of  Making  Bacteeiolog- 
ICAL  Examinations.  —  An  immediate 
microscopical  examination  of  the  exu- 
date in  cases  of  suspected  diphtheria 
will  often  justify  a  positive  diagnosis. 
A  bit  of  membrane  removed  from  the 
throat  by  a  swab  is  smeared  upon  a 
cover-glass  or  slide,  dried,  fixed  by  heat, 
and  then  stained  with  LoefHer's  methy- 
lene-blue  solution. 

With  an  oil  immersion  lens  we  may 
then  be  able  to  determine  the  presence 
of  bacilli  sufficiently  characteristic  to 
warrant  a  positive  diagnosis.  The  ba- 
cilli under  such  conditions  do  not  have 
the  characteristic  features  which  are 
presented  by  cultures  upon  suitable 
media.  They  are  much  more  irregular 
in  size,  shape,  and  staining  properties. 
Positive  judgment  is,  therefore,  much 
more  difficult  and  uncertain.  Failure 
to  find  the  bacilli  by  this  method  would 
in  no  way  prove  that  the  case  was  not 
diphtheria.  The  uncertainties  of  the 
method  are  so  pronounced  that  it  is 
rarely  employed. 

Jlcthod  adopted  by  Chicago  Health 
Department  for  making  early  diagnosis 
of  diphtheria  consists  in  spreading  a 
little  mucus  from  the  throat  on  a  slide, 
allowing  it  to  dry,  then  staining  and 
examining  microscopically  iiuniediately. 
In  about  50  per  cent,  of  cases  a  suffi- 
cient number  of  bacilli  is  found  to  war- 
rant a  diagnosis.  In  case  the  Klcbs- 
I.oeffler  bacilli  cannot  be  found  in  this 
way,  patients  lose  little  by  waiting  for 
incubation  of  cultures.  During  four 
years  the  mortality  of  38  per  cent,  from 
diphtheria,  not  including  laryngeal  cases, 
has  fallen  in  Chicago  to  6.7  per  cent.,  in- 


520 


DIPHTHERIA.    DIFFEEEXTIAL  DU.GXOSIS. 


eluding  all  forms  of  the  disease.  This 
is  thought  to  be  due  to  the  improved 
methods  by  which  early  diagnosis  is 
made  possible,  and  the  early  use  of  anti- 
toxin. W.  K.  Jaques  (Jour.  Amer.  Med. 
Assoc.,  Oct.  29,  '9S). 

With  modification  of  Neisser's  stain 
by  Concetti  it  is  possible  to  arrive  at  a 
very  early  bacteriological  diagnosis. 
The  method  is  as  follows:  A  sterilized 
glass  or  iron  rod  has  twisted  upon  its 
end  a  small  piece  of  absorbent  cotton, 
impregnated  with  glucose  glycerinated 
agar-agar.  The  rods  are  kept  in  steril- 
ized test-tubes,  ^^^len  a  culture  is  to 
be  made,  it  is  removed,  the  affected  part 
swabbed  with  the  end  containing  the 
culture-medium,  and  the  rod  at  once  re- 
placed in  the  tube.  It  is  then  placed  in 
a  thermostat  and  kept  at  a  temperature 
of  36°  to  37°  C.  In  four  or  five  hours' 
time  there  will  have  been  sufficient 
growth  to  make  a  smear.  The  latter  is 
stained  with  a  methylene-blue  solution 
consisting  of  metliylene-blue,  1  gramme ; 
alcohol,  20  cubic  centimetres;  distilled 
water,  450  grammes;  acetic  acid,  5 
grammes.  This  solution  should  remain 
on  the  slide  not  more  than  two  or  three 
seconds.  The  spread  is  then  washed 
with  water,  after  which  it  has  an  in- 
tense-blue color.  A  counterstain  is  em- 
ployed consisting  of  2  grammes  of  vesu- 
vin  in  1000  grammes  of  water.  This  so- 
lution is  heated,  and  filtered  while  still 
warm.  The  specimen  should  be  exposed 
to  the  action  of  the  vesuvin  from  15  to 
20  seconds  and  then  washed  in  water. 
It  displaces  the  methylene-blue.  If  no 
Loeffler  bacilli  are  present,  the  gross 
appearance  of  tlie  smear  is  brown.  The 
presence  of  tlie  true  or  pseudobacilli 
gives  a  mixed  blue  and  brown  color. 
Under  the  microscope  the  pseudobacilli 
are  stained  brown  in  their  entirety. 
The  true  bacilli  liave  a  brown  stain,  but 
the  ends  of  the  bacilli  present  the  char- 
acteristic blue  points,  which  is  the  chief 
differential  test.  A.  L.  Goodman  (Med. 
Record,  Feb.  10,  1901). 

While  in  fcrliiin  Krnall  percentage  of 
cases  the  dipht  licria  bacillus  fails  to 
appear  in  the  first  cultures,  the  fiiilure 
i»  generally  duo  to  a  conjoined  infection 


with  the  septic  micrococci.  Apart  from 
these  instances,  the  fact  that  diphtheria 
is  not  present  can  be  based  on  one 
negative  culture  up  to  the  tenth  day  of 
the  disease.  The  reasons  for  requesting 
a  comfirmatory  culture  in  negative  eases 
are:  1,  where  there  is  no  growth  what- 
ever on  the  culture  media;  2,  where 
there  is  complete  contamination  and 
liquefaction  of  culture  media,  in  cases 
which  are  clinically  diphtheria;  3,  cases 
where  there  are  suspicious  bacilli;  4,  in 
croup  cases  where  the  membrane  is  lim- 
ited to  the  larynx  and  the  duration  of 
the  disease  is  less  than  five  days.  Dry- 
ness of  culture  media,  scanty  growth  and 
the  recent  use  of  antiseptics  with 
satisfactory  growth  of  other  organisms 
than  the  diphtheria  bacilli,  do  not  alone 
furnish  sufficient  grounds  to  demand  a 
comfirmatory  culture.  J.  S.  Billings,  Jr., 
(N.  Y.  Med.  Jour,  and  Phila.  j\Ied.  Jour., 
Sept.  12,  1903). 

The  best  culture-medium  for  routine 
work  is  the  Loeffler  blood-serum,  coag- 
ulated by  heat  in  test-tubes  in  such  a 
way  as  to  give  an  extensive  slanting  sur- 
face for  inoculation.  The  swabs  used  In 
obtaining  the  infected  material  from  the 
throat  are  made  by  wrapping  a  small 
quantity  of  absorbent  cotton  about  the 
end  of  a  small  steel  rod  six  inches  in 
length.  The  swabs  so  made  are  inserted 
into  test-tubes,  which  are  then  plugged 
with  cotton  and  the  whole  sterilized  by 
exposure  to  dry  heat  at  150°  C.  for  one 
hour.  To  make  a  satisfactory  culture 
a  good  view  of  the  throat  must  be  ob- 
tained and  the  swab  rubbed  upon  the 
surface  covered  by  membrane,  or — in 
the  absence  of  membrane — upon  the  in- 
flamed parts.  In  laryngeal  cases  where 
no  membrane  is  visible  it  usually  suffices 
to  make  the  application  of  the  swab 
either  to  the  tonsils  or  as  low  in  the 
pharynx  as  possible.  In  such  cases  if 
the  first  culture  fail  to  show  the  pres- 
ence of  diphtheria  bacilli,  it  is  always 
well  to  repeat  the  process,  as  a  second  or 
third  culture  may  show  the  bacilli  pre- 


UIPHTHKKIA.     DIFFEKKNTIAL  DIAGNOSIS. 


521 


viously  absent  from  the  accessible  parts 
of  the  throat.  Care  must  be  taken  in 
inoculating  the  swab  not  to  allow  it  to 
touch  the  tongue  or  any  other  part  or 
surface  than  the  one  upon  which  the 
presence  of  the  bacilli  is  suspected. 
Otherwise  contaminating  bacteria  are  in- 
oculated upon  the  culture-media  and  the 
value  of  the  culture  for  diagnostic  pur- 
poses destroyed. 

To  carry  out  these  directions  in  young 
children  it  is  necessary  that  they  be  care- 
fully held.  The  best  method  is  to  have 
the  mother  or  nurse  hold  the  child  upon 
her  right  side,  the  child's  face  turned 
toward  the  light  and  the  head  resting 
upon  her  right  shoulder,  one  of  the  hold- 
er's arms  about  the  patient's  legs,  the 
other  controlling  the  arms.  The  physi- 
cian can  then  usually  insert  a  tongue 
depressor  and  control  the  head  with  one 
hand,  while  with  the  other  the  swab  can 
be  properly  directed.  With  very  fractious 
children  it  may  oven  be  necessary  to  have 
a  second  assistant  hold  the  child's  head. 
Failure  to  take  pains  in  making  a  proper 
application  of  the  swab  is  accountable 
for  many  of  the  unsatisfactory  results  ob- 
tained from  cultures.  The  swab  having 
been  properly  inoculated,  the  cotton 
stopper  is  withdrawn  from  the  mouth  of 
the  tube  containing  the  solidified  blood- 
serum  and  the  swab  then  rubbed  gently 
over  the  surface  of  the  culture-medium, 
care  being  taken  not  to  break  the  smooth 
surface  of  the  medium.  The  swab  is 
then  withdrawn,  the  cotton  stopper, 
which  must  have  been  held  so  as  to  have 
escaped  contamination  from  any  outside 
source,  replaced  in  the  mouth  of  the 
culture-tube,  the  swab  dropped  into  its 
tube  again  and  confined  by  its  own  stop- 
per. The  culture-tubes  are  (hen  ready 
for  incubation.  Koplik  has  described  a. 
rapid  method  of  incubation  and  examina- 


tion in  which  he  allows  only  two  or  three 
hours'  incubation  at  37°  C,  at  the  end 
of  which  time  he  asserts  that  the  growth 
of  the  diphtheria  bacilli  is  more  charac- 
teristic than  at  any  other  period  of  in- 
cubation. 

There  is  no  positive  criterion  by  whicli 
the  true  diphtheria  bacillus  can  be  rec- 
ognized in  culture  after  twenty-four 
hours.  The  pseudodiphtheria  bacillus  is, 
culturally,  practically  indistinguishable 
from  it,  difTering  only  in  its  lack  of 
virulence.  Hoffman  considers  the  pseudo- 
diphtheria  bacillus  a  constant  inhabit- 
ant of  the  mouth.  Roux  and  Yersin 
found  it  twenty-si.\  times  in  fifty-nine 
children  of  a  village  on  the  coast  of 
France  in  wliich  diphtheria  was  entirely 
absent.  Bech  discovered  it  twenty-six 
times  in  sixty-six  Iiealthy  cliildren.  In 
view  of  this,  what  value  can  a  method 
possess  by  which,  in  the  required  time 
of  twenty-four  hours,  it  is  impossible  to 
distinguish  the  true  diphtheria  bacillus 
from  a  constant  inhabitant  of  the  mouth? 
The  length  of  the  bacilli  has  been  fre- 
quently regarded  a  characteristic  feat- 
ure, but  very  long  bacilli  with  all  the 
qualities  of  the  Loeffler  bacilli,  except 
that  they  were  non-virulent,  were  found 
in  the  conjunctival  sac.  The  true  diph- 
theria bacillus  in  culture,  especially  on 
white  of  egg,  exhibits  a  sort  of  giant- 
growth,  and  presents  true  brandling,  a 
phenomenon  also  observed  in  the  growth 
of  the  conjunctival  bacillus.  In  view 
of  all  these  facts,  it  is  plainly  not  pos- 
sible to  distinguish  the  virulent  from 
the  non-virulent  bacillus,  and  too  much 
importance  should  not  attach  to  bacterio- 
logical diagnosis  without  determination 
of  virulence,  especially  when  the  diag- 
nosis is  made  within  twenty-four  hours. 
Schanz  (Hcrl.  klin.  Woch.,  Jan.  18,  '97). 

Upon  blood-scrum  and  agar  the  xerosis 
bacillus  resembles  closely  the  diphtheria 
bacillus.  It  is  not  pathogenic  for  ani- 
mals. It  grows  more  abundantly  on 
LoefTler  blood-scrum  and  on  peptone-agar 
than  the  pseudobacillus.  Neisser's 
method  of  staining  decolorizes  the  xero- 
sis and  pseudobacillus,  while  the  diph- 


522 


DIPHTHEKIA.    DIFFERENTIAL  DIAGNOSIS. 


theria  bacillus  retains  the  stain.    Bouil- 
lon is  rendered  acid  by  the  diphtheria 
bacillus,  alkaline  by  the  xerosis  bacillus, 
and   it   is  not   affected   by   the   pseudo- 
diphtheria  bacillus.     E.  Franke  (Munch, 
med.  ^Voch.,  Apr.  19,  '9S). 
When  there  is  no  special  reason  for 
haste,  it  is  usually  more  convenient  to 
adopt  the  method  followed  by  the  New 
York  Board  of  Health,  of  twelve  hours' 
exposure,  the  cultures  are  kept  at  body- 
temperature  over  night  and  are  ready 
for  examination  in  the  morning. 

It  is  not  possible  to  determine  the  pres- 
ence or  absence  of  diphtheria  bacilli  in 
the  cultures  upon  the  blood-serum  from 
the  gross  appearances;  but  if  it  is  found 
that  the  culture-medium  has  been  lique- 
fied during  the  incubation,  it  can  safely 
be  said  that  contaminating  bacteria  are 
present  in  such  numbers  as  to  render  the 
culture  valueless.     The  diphtheria  ba- 
cilli or  cocci  do  not  liquefy  the  medium. 
The    true    diphtheria    bacilli    do    not 
grow   in   fluid   antitoxic   serum,   nor   do 
non-virulent    pseudobaeilli    that    render 
bouillon  acid,  while  virulent  organisms 
that     render     bouillon     alkaline     grow 
equally   well   in   liquid   antitoxic   serum 
and  normal  sei-um.     All  forms  grow  ex- 
cellently upon  antitoxic  serum  that  has 
been  coagulated  at  70  degrees.    De  Mar- 
tini (Centralb.  f.  Bakt.,  Parasit.,  u.  Infr., 
Jan.  30,  '97). 
Upon  the  centre  of  a  clean  cover-glass 
is  placed  a  drop  of  sterile  water.    With  a 
sterile  platinum  loop  a  number  of  the 
colonies,  wbich  show  themselves  as  fine, 
granular  elevations  upon  the  culture  sur- 
face, are  swept  off.    The  loop  is  then  im- 
mersed in  the  water  upon  the  cover-glass 
and  its  contents  spread  evenly  over  the 
glass.     Tlie  preparation  after  being  al- 
lowed to  dry  in  the  air  is  fixed  by  pass- 
ing it  three  times  through  a  moderate 
gas-flame.     It  is  then  stained  by  cover- 
ing it  with  Loeffler's  alkaline  methylene- 
blue  solution  and  allowing  it  to  stand  for 
ten  minutes.     The  cover-glass  is  then 


washed,  dried,  and  mounted  in  Canada 
balsam. 

The  following  is  recommended  as  a  dif- 
ferential stain  for  the  diphtheria  ba- 
cillus:— 

{A)  One  gramme  of  methylene-blue 
(Gi"ubler's)  is  dissolved  in  20  cubic  cen- 
timetres of  96-per-cent.  alcohol,  Avhich  is 
then  mixed  with  950  cubic  centimetres 
of  distilled  water  and  50  cubic  centime- 
tres of  glacial  acetic  acid. 

(C)  Two  grammes  of  vesuvin  are  dis- 
solved in  1  litre  of  boiling  distilled  water 
and  filtered. 

The  cover-glass  preparations  are  stained 
in  A  for  I  to  3  seconds,  rinsed  in  water, 
and   stained  in  B  for  3   to  5   seconds, 
washed   in  water,  dried,   and  mounted. 
Stained  in  this  manner,  the  bacilli  are 
brown,  and  contain  two,  or  rarely  three, 
but   never   more,   blue   corpuscles.     The 
corpuscles  are  oval,  not  round,  in  shape, 
and  their  diameter  appears  greater  than 
that  of  the  bacilli  in  which  they  are  situ- 
ated.    Neisser    {Zeitschr.    f.    Hyg.,    vol. 
xxiv,  No.  3,  p.  443,  '97). 
The  examination  is  made  with  a  Via 
oil  immersion  lens.     In  a  large  propor- 
tion of  the  cases  we  see  an  almost-pure 
culture  of  the  diphtheria  bacillus;   next 
most  frequently  cultures  of  cocci,  single 
double,  or  in  chains;   in  some  cases  the 
cocci  and  bacilli  are  about  equal  in  num- 
ber, and  in  a  small  number  only  a  few 
diphtheria    bacilli    are    seen    scattered 
among  great  numbers  of  cocci.     From 
time  to  time  we  see  in  the  cultures  ba- 
cilli which  closely  resemble  the  diph- 
theria bacilli,  but  with  certain  definite 
points  of  distinction,  and  pseudodiph- 
theria  bacilli.     The   diphtheria  bacilli 
seen  in  such  cover-glass  preparations  vary 
in  length  from  1.5  to  6.5  millimetres, 
and  in  diameter  from  0.3  to  0.8  millime- 
tres. They  occur  singly  or  in  pairs,  rarely 
in  chains  of  three  or  four.    The  rods  are 
straight  or  slightly  curved  and  are  not 
usually  uniformly  cylindrical  through- 
out their  length,  but  arc  swelled  at  the 
ends,  or  pointed  at  the  ends  and  swelled 


DIPHTHERIA.    DIFFERENTIAL  DIAGXOSIS. 


523 


in  the  middle.  The  variety  in  size  and 
shape  even  from  the  same  culture  is  char- 
acteristic. When  in  pairs,  the  bacilli 
may  lie  with  their  axes  in  the  same  line 
or  forming  an  acute  or  obtuse  angle; 
sometimes  they  are  crossed.  The  bacilli 
show  no  spores,  but  may  contain  highly,- 
refractile  bodies,  especially  in  their 
swelled  portions.  When  grown  upon 
blood-serum  and  stained  in  the  manner 
above  described,  the  bacilli  stain  in  a 
peculiarly-characteristic  way.  Lack  of 
uniformity,  both  in  the  individual  ba- 
cillus and  in  the  numbers  of  groups,  is 
marked.  Thus,  different  parts  of  a  ba- 
cillus take  the  stain  unequally;  so  that 
the  ends  are  dark  blue,  while  the  centre 
shows  little  or  no  color,  or  vice  versa. 
Likewise  bacilli  lying  side  by  side  show 
marked  difference  in  coloring,  one  being 
much  more  deeply  stained  than  the 
other.  This  lack  of  uniformity  in  the 
staining  of  the  bacilli  seems  to  belong  to 
a  certain  period  of  their  growth;  it  is 
usually  marked  after  the  twelve-hour  in- 
cubation, but  many  disappear  entirely  in 
older  cultures. 

Mention  has  already  been  made  of  ba- 
cilli found  in  cultures  resembling  the 
diphtheria  bacillus  and  yet  not  possess- 
ing the  specific  pathogenic  properties  of 
that  bacillus,  and  therefore  termed  pseu- 
dodiphthcria  bacilli.  This  term  is  most 
unfortunate,  since  these  bacilli  bear  no 
relation  to  the  throat  inflammation 
termed  pscudodiphtheria.  As  seen  in 
cover-glass  preparations,  these  bacilli  are 
shorter,  plumper,  and  more  uniform  in 
size  and  staining.  They  are  most  often 
met  with  in  cultures  from  the  nose. 
When  obtained  in  pure  cultures,  these 
bacilli  have  been  shown  to  be  devoid  of 
virulence. 

As  seen  under  the  microscope,  the  uni- 
formity in  size,  shape,  and  staining  is 
sufficiently  marked  from  the  variations 


in  these  points  noted  with  reference  to 
the  diphtheria  bacillus  to  enable  prac- 
ticed observers  to  recognize  them  readily. 

In  the  diagnosis  of  diphtheria  the  sim- 
ple microscopical  method  of  examining 
the  exudate  is  a  great  deal  better  than 
any  clinical  method.  All  that  is  needed 
is  a  good  microscope,  with  an  Abbfi  con- 
denser and  oil-Immersion  lens.  Also  a 
few  slides  are  required,  and  some  LofHer 
alkaline  blue.  If  one  meets  with  a  sus- 
picious ease,  all  that  is  necessary  is  to 
ask  for  a  whalebone  or  stout  stick  and 
wrap  a  bit  of  absorbent  cotton  on  the 
end.  This  swab  should  be  rubbed  on  the 
exudate  very  firmly;  then  it  can  be  put 
in  an  envelope  or  other  simple  container 
and  examined  in  the  office.  To  do  this, 
one  should  moisten  a  clean  glass  slide 
with  a  drop  of  water  and  rub  the  swab 
around  in  it  for  a  minute.  Then  the 
swab  sliould  be  burned  and  the  prepara- 
tion dried.  When  it  is  thoroughly  dry, 
it  is  passed  through  a  flame  three  times 
at  such  a  rate  that  the  exudate  is  baked 
and  will  not  wash  off.  On  the  other 
hand,  it  should  not  be  heated  so  that 
the  preparation  is  distorted  and 
scorched.  After  heating,  one  should 
run  on  the  slide  a  drop  or  two  of 
Lflffler's  blue,  sufficient  to  cover  the 
dried  exudate,  then  wash  off  the  stain, 
dry  thoroughly  with  blotting-paper,  and 
drop  on  a  little  cedar-oil  and  examine. 
The  whole  process  takes  about  a  minute 
or  two. 

If  the  case  is  diphtheria,  the  first 
thing  that  will  attract  the  eye  are 
masses  of  fibrin  stained  deeply  blue. 
These  masses  are  stringy  in  texture.  In 
these  masses  of  fibrin  and  outside  pecul- 
iar bacilli  may  be  seen.  They  are  al- 
ways more  or  less  curved.  They  are 
never  of  perfectly  even  width.  They  are 
often  clubbed  at  one  or  both  ends,  or 
they  may  taper  at  one  or  both  ends. 
These  organisms  never  take  the  stain 
evenly;  the  substance  of  the  bacilli 
appears  much  denser  in  places,  so  that 
the  organism  appears  to  have  bands  or 
stripes.  Bacilli  often  appear  broken  in 
the  middle,  or  there  seems  to  be  an 
achromatic  juncture. 

But  what  is  far  more  characteristic  is 


524 


DIPHTHERIA.    DIFFEEEN'TIAL  DIAGNOSIS. 


the  presence  of  little  black  or  bluish- 
black  points  very  often  situated  at  one 
or  both  poles  of  the  bacUlus,  with  occa- 
sionally a  little  point  in  the  middle.  If 
these  point-bearing  bacilli  are  found  in 
the  fibrin,  one  can  be  very  certain  that 
the  case  is  diphtheria.  There  are  many 
other  organisms  foimd  in  diphtheritic 
membrane  by  this  method,  but  if  they 
contain  chromatin  granules  and  are 
curved  and  irregular  in  outline,  they  are 
diphtheria  bacilli.  If  the  case  is  ton- 
sillitis, by  the  same  method  single  round 
cocci  or  streptococci  or  diploeocei  are  to 
be  found,  but  no  chromatin  point-bear- 
ing little  rods  will  be  seen. 

A  diagnosis  of  diphtheria  should  not 
be  made  unless  these  chromatin  points 
are  found.  The  preparation  shotild  be 
properly  heated,  and  it  is  most  impor- 
tant that  the  stain  be  good.  A  poor 
stain  will  not  differentiate  the  chroma- 
tin points.  Chromatin  points  appear  in 
other  organisms,  as  has  been  seen  in 
long  bacilli  grown  on  potato  and  found 
in  water,  but  the  organisms  were  three 
or  four  times  longer  than  the  diph- 
theria bacillus;  they  were  straight  and 
of  even  width,  except  where  the  chro- 
matin points  bulged  through  the  con- 
tinuity, so  that  the  organism  resem- 
bled a  jointed  bamboo  cane.  It  is  said 
that  a  bacUlus  which  is  pathogenic  for 
mice  also  exhibits  chromatin  spots.  But 
it  is  rare  to  find  such  organisms  in  the 
throat,  and  much  rarer  to  find  them  in 
pseudomcmbrane.  R.  L.  Pitfield  (Univ. 
of  Penna.  Med.  Bull.,  Sept.,  1901). 

Whenever  we  find  the  characteristic 
bacilli  above  described  present  in  the 
cover-glass  preparations,  we  can  safely 
set  the  case  down  as  one  of  true  diph- 
theria, however  few  the  bacilli  may  be 
in  number  in  the  smear,  or  with  what- 
ever other  bacteria  combined.  If  the 
diphtheria  bacilli  are  found  at  all,  a 
second  culture  usually  shows  them 
greatly  exceeding  in  numbers  any  other 
form  of  bacteria  present,  and  the  cases 
will  be  found  to  present  the  clinical 
symptoms  of  diphtheria. 

In  any  case,  to  render  the  bacteriolog- 


ical diagnosis  complete,  it  would  be  nec- 
essary to  obtain  the  diphtheria  bacilli  in 
pure  culture  and  test  their  virulence  by 
inoculation  of  susceptible  animals. 

In  routine  practice  this  is  done  by  in- 
oculating half-grown  guinea-pigs  with 
from  V4  to  V2  per  cent,  of  their  body- 
weight  of  a  forty-eight  hours'  culture  of 
the  bacilli  grown  at  37°  C.  in  simple 
nutrient  or  glucose  alkaline  broth.  In 
carrying  out  such  experimentation  many 
precautions  are  necessary  to  render  such 
work  accurate  and  trustworthy.  Much 
time  and  labor  are  consumed  in  the  proc- 
ess. For  our  purposes  it  is  suiRcient  to 
know  that  the  great  majority  of  those 
who  have  carried  on  such  experiments 
under  proper  conditions  with  bacilli  de- 
rived from  pseudomembranes  and  pre- 
senting the  morphological  and  staining 
characters  of  diphtheria  bacilli  have 
found  the  bacilli  fully  virulent. 

So  long  as  the  bacteriological  diagnosis 
is  reinforced  by  clinical  evidence  of  the 
presence  of  false  membrane  and  the 
symptoms  of  diphtheria,  we  can  safely 
trust  to  the  examination  of  these  cover- 
glass  preparations. 

We  find,  however,  that  the  examina- 
tion of  healthy  throats  has  led  to  some 
remarkable  results.  In  the  throats  of 
those  who  have  been  exposed  to  diph- 
theria, but  have  remained  perfectly  well, 
we  may  find  characteristic  and  fully  viru- 
lent diphtheria  bacilli;  in  others  we  may 
find  the  pscudodiphtheria  bacillus  al- 
ready spoken  of,  or  a  bacillus  which, 
while  presenting  the  cultural  and  mor- 
phological characters  of  the  diphtheria 
bacillus,  proved  in  inoculations  to  be 
non-virulent. 

Thus,  in  a  series  of  330  healthy  throats 
examined  by  the  New  York  Board  of 
ITealth,  in  8  virulent  characteristic  diph- 
theria bacilli  were  found,  in  24  non-vir- 
ulent   characteristic   diphtheria   bacilli, 


DIPHTHERIA.    ETIOLOGY. 


525 


and  in  27  non-virulent  pseudodiph- 
theria  bacilli.  Since  Hoffmann's  obser- 
vation of  these  bacilli,  so  closely  resem- 
bling the  Loeffler  bacillus,  but  devoid  of 
virulence,  a  great  deal  of  attention  has 
been  given  to  this  subject.  Opinion  is 
still  divided  as  to  the  relation  of  these 
non-virulent  bacilli.  On  the  one  hand, 
they  are  regarded  simply  as  degenerate 
or  attenuated  forms  of  the  diphtheria 
bacillus;  on  the  other,  they  are  repre- 
sented as  a  distinct  species. 

The  identity  of  the  pseudodiphtheria 
bacillus  seems  to  be  now  established.  In 
form  these  are  smaller,  shorter,  and 
thicker  than  the  diphtheria  bacillus. 
When  seen  in  stained  smears  the  bacilli 
are  often  observed  to  be  lying  parallel 
to  one  another,  in  contrast  to  the  irregu- 
larly-angular disposition  of  the  diph- 
theria bacillus.  In  their  growth  in 
broth  the  pseudodiphtheria  bacilli  de- 
velop alkali,  where  the  Loeffler  bacillus 
forms  acid.  They  are  never  virulent. 
These  differences  are,  by  most  authori- 
ties, considered  sufficient  to  warrant  the 
belief  that  they  are  a  separate  species. 

The  other  class  of  non-virulent  bacilli 
found  in  the  throat  present  all  the  char- 
acters of  the  Loeffler  bacillus  except  their 
virulence.  Roux  and  Yersin  believed 
these  bacilli  to  be  simply  attenuated 
forms  of  the  diphtheria  bacillus.  It  was 
shown  that  they  are  particularly  likely 
to  be  met  with  in  the  throats  of  those 
who  have  had  diphtheria  some  time  be- 
fore, or  have  been  exposed  to  diphtheria. 
It  was  also  found  that  the  diphtheria 
bacillus  could  be  so  attenuated  by  vari- 
ous methods  of  growth  as  to  deprive  it 
of  its  virulence.  No  one,  however,  has 
yet  been  able  to  restore  virulence  to  any 
of  the  non-virulent  forms  met  with,  and 
the  question  must  be  considered  as  still 
open. 


There  are  70  varieties  of  diphtheria 
and    pseudodiphtheria    bacilli   from    the 
standpoint    of    agglutination    by    anti- 
diphtheritic  serum.    This  property  is  an 
inconstant    characteristic    of    the    true 
Klebs-Liifller  bacillus,  and  is  in  no  way 
related  to  its  virulence.     Certain  varie- 
ties  of   this   organism   can   be   aggluti- 
nated by  the  serum  of  horses  immunized 
by  cultures,  while  they  do  not  react  to 
the  serum  of  horses  immunized  by  tox- 
ins.    The  pseudobacillus  conducts  itself 
toward  these  sera  precisely  as  does  the 
true  organism,  and  by  this  means  can- 
not    be     differentiated     from     it.      Ch. 
Lesieur  (Comptes  Soc.  de  Biologic,  Aug., 
1901). 
Etiolo^. — As  early  as  1879  Klebs  is 
said  to  have  observed  the  presence  of  a 
peculiar  bacillus  in  cases  of  diphtheria. 
In  18S3  his  observations  of  the  presence 
of  this  bacillus  in  the  pseudoraembranes 
from  the  throats  of  those  dpng  of  epi- 
demic   diphtheria    were    reported    and 
brought  to  general  attention.     In  1884 
Loeffler  published  the  results  of  his  ob- 
servations.    He  had  found  the  bacillus 
present  in  the  great  majority  of  cases 
diagnosticated  as  diphtheria,  had  been 
able  to  obtain  the  bacillus  in  pure  cult- 
ure, had  inoculated  it  upon  the  abraded 
mucous  membranes  of  suscejjtible  ani- 
mals and  thereby  produced  pseudomem- 
branous inflammation,  often  followed  by 
death;  he  had  injected  bouillon  cultures 
of  the  bacillus  subcutaneously  and  had 
found    characteristic    lesions    after    the 
death  of  the  animals  so  treated.    In  1888 
d'Espine  found   the  bacilli   present   in 
fourteen  cases  of  typical  diphtheria,  and 
proved  them  to  be  absent  in  24  cases  of 
mild  sore  throat,  not  presenting  the  clin- 
ical characters  of  diphtheria.     In  the 
same  year  Roux  and  Yersin  reported  that 
they  had  found  bacilli  presenting  the 
characters  described  by  Loeffler  in  all 
cases     of     typical     diphtheria.       They 
showed  that  wlien  inoculated  upon  the 
healthy  mucous  membrane  of  the  trachea 


526 


DIPHTHERIA.    ETIOLOGY. 


of  rabbits  no  effect  was  produced;  but, 
if  the  membrane  \rere  previously  abraded 
tbe  symptoms  of  pseudomembranous 
lanTigitis  in  men  followed.  Congestion 
of  tbe  mucous  membrane,  the  formation 
of  pseudomembrane,  swelling  of  the 
glands  and  cellular  tissues  of  the  neck, 
dyspncea,  stridor,  and  asphyxia.  From 
that  time  on  numerous  observations  were 
made  in  France,  Germany,  and  America, 
until,  in  1891,  Welch  declared  that  all 
the  conditions  necessary  to  the  demon- 
stration of  the  specific  relation  of  the 
Klebs-Loeftler  bacillus  to  diphtheria  had 
been  met:  (1)  its  constant  presence  in 
cases  of  true  diphtheria,  (2)  its  isolation 
in  pure  culture,  and  (3)  the  production 
of  all  the  symptoms  of  the  disease  by  the 
Inoculation  of  pure  cultures  in  suscep- 
tible animals.  Since  that  time  evidence 
has  been  accumulated  from  many 
sources,  till  there  can  no  longer  be  any 
doubt  that  the  essential  cause  of  diph- 
theria is  the  growth  and  development  of 
this  bacillus  within  the  body.  The  de- 
velopment of  the  disease  must,  there- 
fore, be  dependent  in  every  case  upon 
the  presence  and  action  of  the  diphtheria 
bacillus. 

The  disease  is  common  in  all  parts  of 
the  land.  In  the  cities  it  is  usually  en- 
demic, the  frequence  and  virulence  of 
the  disease  varying  from  year  to  year; 
in  rural  communities  it  usually  occurs  as 
distinct  epidemics,  each  new  outbreak 
being  dependent  upon  the  introduction 
of  the  disease  from  without.  It  may  also 
occur  sporadically.  It  does  not,  how- 
ever, in  any  case  arise  de  novo.  Each 
new  case  is  developed  by  infection,  how- 
ever remote,  from  some  previous  one. 
The  infection  may  be  either  direct  or 
indirect.  Direct  infection  is  undoubt- 
edly most  common. 

The  bacilli  arc  usually  present  in  great 
numbers    in    the    discharges    from    the 


throat  or  nose  of  the  patients,  in  the 
saliva,  and  in  the  membranes  which  may, 
from  time  to  time,  be  coughed  up.  They 
are  not,  so  far  as  evidence  is  had,  present 
in  the  breath  of  the  patients,  but  may 
abound  in  the  air  of  the  room  or  rooms 
inhabited  by  them.  The  bacilli  have 
even  been  reported  as  present  in  the 
urine  of  patients. 

The  genitals  of  every  female  child  who 
contracts  diphtheria  in  its  throat  should 
be  examined.  Coues  (Boston  Med.  and 
Surg.  Jour.,  May  12,  '9S). 

Direct  contact  with  the  discharges 
from  the  nose  or  throat  of  those  suffering 
from  diphtheria  is  most  dangerous. 
Many  a  physician  has  fallen  victim  to 
diphtheritic  infection  received  by  allow- 
ing a  child  to  cough  in  his  face  during 
the  process  of  examination.  Kissing  the 
patients  may  likewise  be  the  means  of 
infection  in  many  cases. 

While  severe  cases  are  usually  due 
to  the  action  of  virulent  bacilli  and  may, 
therefore,  be  especially  potent  in  trans- 
mitting the  disease,  it  is  not  to  be  for- 
gotten that  apparently  mild  cases  may 
harbor  bacilli  just  as  virulent  and  just  as 
much  to  be  avoided.  As  already  re- 
marked, the  most  virulent  bacillus  Park 
has  met  with  was  derived  from  a  mild 
case  of  diphtheria.  The  cases  of  virulent 
pharyngeal  diphtheria  are  most  danger- 
ous on  account  of  the  quantity  of  the 
discharge.  Purely  laryngeal  cases  have 
little  or  no  discharge,  and  are  conse- 
quently less  likely  to  spread  the  infec- 
tion. 

The  bacteria  may  linger  in  the  throat 
for  weeks  after  the  disappearance  of  all 
clinical  symptoms  and  the  patients  con- 
tinue throughout  the  period  to  be  sources 
of  infection. 

In  245  of  405  caHcs  the  diplitlieria  ba- 
eilli  disappeared  within  three  days  after 
the  complete  separation  of  the  false  mem- 
brane; in  100  cases  the  diphtheria  bacilli 


DIPHTHERIA.    ETIOLOGY. 


527 


persisted  in  103  cases  for  seven  days;  In 
34  cases  for  twelve  days;  in  10  cases  for 
fifteen  days;  in  4  for  three  weeks;  and 
in  3  for  five  weeks.  In  many  of  these 
cases  the  patients  were  apparently  well 
many  days  hefore  the  infectious  agent 
had  disappeared  from  the  throat.  N.  Y. 
Health  Board  {Annual,  vol.  i,  "95). 

Indirect  infection  may  cecur  by 
means  of  the  clothing  of  the  patients, 
the  bedding,  carpets,  wall-paper,  draper- 
ies, eating-  or  drinking-  utensils,  tongue- 
depressors,  swabs,  instruments  of  any 
kind  used  upon  or  about  the  patient, 
anything  that  has  come  in  contact  with 
the  infectious  discharges.  Children's 
toys  or  books  are  especially  likely  to  be 
contaminated  and  become  means  of  car- 
rying the  germs  to  others. 

In  some  cases  persons  who  are  them- 
selves perfectly  healthy,  but  who  have 
been  in  contact  with  diphtheria  cases  are 
found  to  harbor  the  bacilli  in  the  nose  or 
throat  and  may  be  the  source  of  infec- 
tion to  others.  On  several  occasions  the 
development  of  a  series  of  cases  of  diph- 
theria in  a  single  nursery  of  the  New 
York  Foundling  Hospital  has  led  to  the 
examination  by  cultures  of  the  throats 
of  all  children  in  that  nursery,  with  the 
result  of  usually  finding  two  or  three 
who,  while  apparently  healthy,  had  typ- 
ical germs  in  their  throats. 

The  isolation  of  these  children  would 
at  once  break  the  succession  of  cases  of 
diphtheria  previously  observed.  It  may 
also  happen  that  physicians  or  nurses 
transmit  the  germs  either  by  their  hands 
or  clothing  from  one  case  to  another. 
The  frequent  occurrence  of  diphtheria 
in  the  families  of  physicians  is  sufficient 
evidence  of  the  need  of  care. 

[If  diphtheria  is  suspected  or  ascer- 
tained, the  physician  should,  before  en- 
tering the  sick-room,  remove  his  coat 
and  vest,  and  cover  his  body,  neck,  and 
extremities  with  a  blouse  or  a  sheet 
fastened    around    his    neck    and    body. 


When  the  physician  has  completed  his 
examination,  and  is  about  leaving  the 
family,  he  should  bathe  his  head,  face, 
beard,  and  hands  in  an  antiseptic  lotion, 
as  one  of  corrosive  sublimate  or  carbolic 
acid.  All  articles  not  required  for  the 
comfort  of  the  patient,  as  carpet,  cur- 
tains, pictures,  and  decorations,  should 
be  removed,  and  all  persons  except  the 
physician  and  those  who  nurse  the  pa- 
tient should  be  excluded  from  the  sick- 
room. J.  Lewis  Smith  and  F.  M.  War- 
ner, Assoc.  Eds.,  Annual,  '94.] 

Apart  from  the  question  of  the  trans- 
mission of  the  disease  from  case  to  case, 
many  other  factors  may  influence  the 
development  and  spread  of  diphtheria. 

Sex  apparently  has  no  influence,  but 
age  materially  influences  the  suscepti- 
bility. Nursing  children  are,  happily, 
remarkably  immune.  The  greatest  sus- 
ceptibility lies  between  the  ages  of  two 
and  five  years;  from  five  to  ten  many 
cases  are  seen;  after  ten  the  suscepti- 
bility diminishes  very  rapidly,  and  in 
adults  it  is  but  slight.  The  following 
table  of  14:,688  deaths  occurring  in  New 
York  in  ten  years,  tabulated  by  Billing- 
ton,  illustrates  these  points: — 

Under  one  year 1,214 

From  one  to  five  years 9,622 

From  five  to  ten  years 3,212 

From  ten  to  fifteen  years. . .  311 

Over  fifteen  vears 329 


Total 1-1,688 

The  season  of  the  year  exerts  some 
influence.  Thus,  in  England  and  Wales 
the  average  number  of  deaths  for  each 
quarter  of  the  year,  from  1870  to  1893 
inclusive,  was  as  follows:  First  quarter, 
1000.  Second  qtiarter,  819.  Third 
quarter,  847.  Fourth  quarter,  1192. 
(Thome.) 

Diphtheria  is,  therefore,  more  com- 
mon during  the  cold  months  of  fall  and 
winter  than  during  the  spring  and  sum- 


528 


DIPHTHEKIA.    ETIOLOGY. 


mer.  The  same  fact  is  borne  out  by 
Bosworth's  analysis  of  1S,6SS  deaths 
from  diphtheria  occurring  in  Xew  York 
d\iring  thirteen  years.  Of  these  10,769 
occurred  from  October  to  March,  and 
7919  from  April  to  September,  inclusive. 

Result  of  an  extended  epidemiological 
inquiry  into  the  incidence  of  diphtheria, 
during  the  twenty  years  of  1877-96,  in 
the  city  of  Catania  (population  in  1896, 
116,000).  During  the  nine  years  of  1877- 
85  the  deaths  per  10,000  at  all  ages  were 
15.8,  while  in  the  nine  years  of  1886-94 
they  fell  to  7.1,  and  in  the  four  years  of 
1893-96  they  were  only  2.7.  These  two 
nine-yearly  periods  were  characterized  by 
a  sudden  rise  in  the  mortality  and  a 
slow  decline,  but  the  maximum  in  the 
first  period  (1879)  was  34  per  10,000, 
while  in  the  second  period  it  was  16. 

Taking  the  whole  twenty  years,  the 
influence  of  season  is  very  marked.  The 
lowest  month  is  August  (4.8),  and  the 
highest  is  January  (12.25);  and  taking 
the  summer  quarter  as  June,  July,  and 
August,  it  is  5.71;  while  the  autumn 
and  winter  quarters  are  10.9  each,  and 
the  spring  8.3.  The  meteorological  ele- 
ments which  differentiate  the  seasons 
are  temperature,  relative  humidity,  and 
rain-fall.  Taking  the  whole  twenty- 
years'  period,  it  is  shown  by  curves  of 
temperature,  relative  humidity,  and  rain- 
fall that  the  two  latter  agree  directly 
with  the  diphtheria  death-curve,  while 
the  first  agrees  with  it  inversely.  The 
important  consideration  is  the  cause  of 
this  marked  diminution  in  diphtheria 
mortality.  Serum-treatment  is  virtually 
not  practiced  at  all,  and  disinfection  is 
little  followed.  It  is  in  general  sanitary 
improvements  that  the  explanation  is  to 
be  looked  for.  Giagunta  (Gior.  d.  Soc. 
ital.  d'ig..  No.  8,  '98). 

The  massing  of  cliildren  in  schools, 
asylums,  and  hospitals  produces  condi- 
tions favorable  to  the  development  and 
spread  of  diphtheria,  doubtless  by  in- 
creasing the  chances  of  infection.  The 
Bchools  have  often  been  pointed  out  as 
the  sources  of  epidemics  of  diphtheria, 


which  could  only  be  controlled  by  clos- 
ing the  institutions  concerned. 

Out  of  654  convalescent  hospital  cases, 
the  bacillus  was  found  in  309  after  the 
entire  disappearance  of  the  membrane. 
Among  107  of  these,  cultivations  from 
the  throat  gave  negative  results  for 
some  days,  and  then  the  bacillus  wotild 
reappear.  Since  the  same  fact  was  ob- 
served in  discharged  eases,  this  reap- 
pearance was  hardly  due  to  reinfection. 
The  following  list  shows  the  time  the 
bacillus  was  present: — 

Dirlitheria  B«oilh\s  Present 
After  Oisiipiioaranoo  of  Membrane. 


■•     m  ••  .  ..."  10  to   20 

"     5t  "  .  .       .        .        "  20  to   SO  •• 

••     41  "  .  .       .        .        "  30  to   60  " 

6  "  .  .        .       .        "  60  to  120  " 

Disinfectants  for  the  throat  had  been 
carefully  applied.  The  use  of  anti- 
diphtheritic  serum  did  not  prevent  the 
persistence  of  the  bacillus  in  the  upper 
respiratory  tract.  Holger  Prip  (Zeit. 
f.  Hyg.  u.  Infectsk.,  B.  xxxvi,  H.  2,  1901). 

The  following  section  from  the  Bul- 
letin of  the  New  York  Board  of  Health 
is  of  interest  in  this  connection: — 

"It  has  been  the  practice  of  the  De- 
partment to  plot  upon  a  city  map  the 
location  and  date  of  every  case  of  diph- 
theria in  which  the  diagnosis  had  been 
settled  by  bacteriological  examination. 
After  several  months  the  map  presented 
a  very  striking  appearance.  Wherever 
the  densely  settled  tenements  were  lo- 
cated, there  the  marks  were  very  numer- 
ous, while  in  the  districts  occupied  by 
private  residences  very  few  cases  were 
indicated  as  having  occurred.  It  was 
also  apparent  that  the  cases  were  far  less 
abundant,  as  a  rule,  where  the  tenements 
were  in  small  groups  than  in  the  regions 
of  the  city  where  they  covered  larger 
areas.  At  the  end  of  six  months  there 
were  square  miles  in  which  nearly  every 
block  occupied  by  tenement-houses  con- 
tained marks  indicating  the  occurrence 
of  one  or  more  cases  of  diphtheria;  and 
in  some  blocks  many  (15  to  35)  had  oc- 
curred. 


DIPHTHERIA.    ETIOLOGY. 


529 


"As  the  plotting  went  on,  from  time 
to  time  the  map  showed  the  infection 
of  a  new  area  of  the  city,  and  often  the 
subsequent  appearance  of  an  epidemic. 
It  was  interesting  to  note  two  varieties 
of  these  local  epidemics:  in  one  the  sub- 
sequent cases  evidently  were  from  neigh- 
borhood infection,  while  in  the  second 
variety  the  infection  was  as  evidently  de- 
rived from  schools,  since  a  whole  school- 
district  would  suddenly  become  the  seat 
of  scattered  cases.    At  times,  in  a  certain 
area   of   the   city   from   which    several 
schools  drew  their  scholars,  all  the  cases 
of  diphtheria  would  occur  (as  investiga- 
tion showed)  in  families  whose  children 
attended  one  school,  the  children  of  the 
other  schools  being  for  a  time  exempt." 
A  number   of   epidemics   have   been 
traced  to  infected  milk,  the  infection 
arising  from  the  presence  of  diphtheria 
among  those  engaged  in  handling  the 
milk.     Certain  English  observers  have 
also  claimed  to  have  discovered  a  specific 
disease  among  milch  cows,  characterized 
by  an  eruption  of  vesicles  and  pustules 
upon  the  udders  and  teats,  accompanied 
by  the  presence  of  the  diphtheria  bacillus 
in  the  local  lesions,  and  capable  of  being 
reproduced  by  infections  of  the  bacilli. 
Outbreak    of    dipbtlievia    which    was 
traceable  to   the  milk   obtained  from   a 
particular  dairy.     Ernest  Hart,  in  1SS7, 
gave  a  summary  of  14  epidemics  of  this 
disease  traceable  to  milk.    Since  then  a 
number  of  cases  have  been  described,  Init 
none  which  show  more  conclusively  the 
possibility  of  milk  dissemination  of  the 
disease    than    this   epidemic,   which   oc- 
curred    in     Parramatta,     a     suburb     of 
Sj'dney.     The   population   of   the   town 
numbers    10,144,   and   the   location   and 
drainage  of  the  place  are  excellent.    The 
water-supply    is    above    suspicion.     The 
outbreak  of  diphtheria  occuiTcd  in  Oc- 
tober.   From  the  8th  to  the  20th  of  that 
month  40  cases  of  diphtheria  occurred.  In 
46  of  these  the  milk  supply  was  derived 
from  a  single  daiiw,  and  in  the  customers 

2- 


supplied  from  this  dairy,  aside  from  the 
diphtheria  cases,  there  were  05  cases  of 
sore  throat.    E.  S.  Stokes  (Australasian 
Med.  Gaz.,  Oct.  20,  1903). 
Other  outbreaks  of  diphtheria  have 
been  attributed  to  bad  drainage,  defect- 
ive sewers,  or  the  presence  of  an  abun- 
dance of  decomposing  organic  matter.    It 
is  also  held  that  certain  domestic  animals 
— pigeons,  cats,  etc. — are  susceptible  to 
diphtheria  and  may  be  the  means  of 
transmitting  it  to  man. 

However  much  or  little  insanitary  sur- 
roundings may  contribute  to  the  devel- 
opment of  diphtheria,  the  active  and 
essential  cause  must  be  the  diphtheria 
bacillus,  and  our  hope  of  limiting  the 
ravages  of  this  disease  must  be  based 
upon  control  of  the  individual  cases,  each 
of  which  is  a  focus  for  the  farther  spread 
of  the  infection. 

The  tenacity  to  life  of  the  bacillus 
outside  the  body  is  remarkable.  Hof- 
mann  found  that  it  would  live  for  one 
hundred  and  fifty-five  days  on  blood 
serum;  Loeffler  and  Park  for  seven 
months;  and  on  gelatin  Klein  found  it 
living  after  eighteen  months.  On  bits 
of  dried  membrane  found  living  bacilli 
after  fourteen  weeks.  Park  after  seven- 
teen, and  Eoux  and  Yersin  after  twenty 
weeks.  Abel  says  that,  dried  on  silk 
threads,  they  may  live  one  hundred  and 
twenty-two  days  and  upon  a  child's  play- 
thing, kept  in  a  dark  place,  he  found  the 
bacilli  alive  after  five  months. 

The  period  of  incubation  of  diphtheria 
varies  from  two  days  to  a  week.  It  is 
doubtless  affected  by  the  number  and 
virulence  of  the  organisms  present  and 
by  the  resisting  power  of  the  patient.  In 
most  cases  it  is  impossible  to  determine 
the  time  of  exposure,  nuich  less  that  of 
infection.  Second  attacks  of  diphtheria 
are  rare,  but  do  occur.  In  one  case  ob- 
served at  the  Xew  York  Foundlinsj  Hos- 
pital, a  boy  of  4  had  croup  in  March. 
34 


530 


DIPHTHERIA.     PATHOLOGY. 


The  diphtheria  bacilli  were  demon- 
strated in  cultures  from  the  throat. 
Antitoxin  was  given  and  he  recoTered. 
Twenty-five  days  later,  having  been  ap- 
parently well  in  the  meantime,  he  devel- 
oped tonsillar  diphtheria,  which  ex- 
tended to  the  larynx,  pneumonia  devel- 
oped, and  death  followed,  thirty-four 
days  from  the  conclusion  of  the  first  at- 
tack. 

Pathology.  —  The  bacteriological  in- 
vestigations of  recent  years  have  materi- 
ally affected  our  views  of  the  pathology 
of  diphtheria,  "^^e  have  learned  that 
the  local  lesions  of  the  mucous  mem- 
branes really  constitute  a  very  subsidiary 
part  of  the  process.  In  them  the  diph- 
theria bacilli  grow  and  multiply,  devel- 
oping in  their  growth  certain  organic 
substances,  termed  toxins,  which  are 
readily  absorbed  into  the  circulation  and 
by  their  action  produce  constitutional 
symptoms  and  remote  affects  more  char- 
acteristic of  the  disease  than  the  local 
lesions  themselves.  The  diphtheria  ba- 
cilli have  been  found  not  only  upon  the 
mucous  membranes,  but  in  the  lungs, 
liver,  spleen,  lymph-nodes,  kidneys,  and 
even  upon  the  valves  of  the  heart.  They 
are  not,  however,  present  in  great  num- 
bers in  any  of  these  organs;  in  fact,  they 
are,  except  possibly  in  the  case  of  the 
lungs,  so  few  in  number  as  to  be  demon- 
strable only  by  means  of  cultures.  Their 
presence  in  the  viscera  does  not  excite 
characteristic  lesions  of  these  parts,  and 
seems  to  be  an  accidental  accompaniment 
rather  than  an  essential  part  of  the  dis- 
ease. The  action  of  the  toxins,  on  the 
other  hand,  is  characteristic  and  impor- 
tant. These  substances  have  been  iso- 
lated and  studied  especially  by  Brieger 
and  Fraenkel,  Roux  and  Yersin.  They 
have  been  found  to  be  allied  to  the  al- 
bumins, and  have  been  designated  as 
toxalbumins.     In  experimental  inocula- 


tions in  susceptible  animals,  as  shown 
by  Welch  and  Flexner  and  others,  they 
have  been  found  to  produce  all  the  char- 
acteristic features  of  diphtheria  except 
the  membrane,  especially  the  character- 
istic post-diphtheritic  paralysis.  The 
most  striking  of  their  remote  effects  are 
produced  in  the  lymph-nodes  and  liver. 
In  the  lymph-nodes  they  produce  a  dis- 
tinct hyperplasia;  in  the  liver  necrosis 
or  death  of  small  areas  of  liver-cells, 
focal  necroses,  similar  to  those  seen  in 
the  liver  in  typhoid  fever  and  other  in- 
fectious diseases. 

We  must,  therefore,  believe  that  the 

presence  of  these  soluble  poisons  in  the 

circulation  constitutes  a  very  important 

,  feature  of  diphtheria.    These  toxins,  as 

I  already  noted,  are  elaborated  in  the  local 

I  lesions  of  the  mucous  membranes,  and 

not  by  the  bacteria  that  may  be  present 

in  the  various  viscera.    The  quantity  and 

quality  of  the  toxins  generated  seem,  as 

a  rule,  to  be  proportionate  to  the  severity 

of  the  local  process. 

The  following  results  are  reached  from 
a  study  of  the  constitution  of  the  diph- 
theria poisoning:  I.  The  diphtheria  ba- 
cillus produces  two  kinds  of  substances: 
(a)  toxins  and  (6)  toxons,  both  of  which 
combine  with  the  antitoxin.  Toxins  and 
toxons  have  been  found  in  three  fresh 
bouillons  in  the  same  quantitative  rela- 
tion. 2.  The  toxins,  and  probably  also 
the  toxons,  are  not  simple  bodies,  but 
they  break  up  into  various  subdivisions, 
which  differ  in  their  affinity  for  the  anti- 
toxin. Three  groups  can  be  distin- 
guished: prototoxins,  deuteroto.xins,  and 
tritotoxins.  3.  This  division  does  not 
exhaust  the  complication,  for  it  must  be 
assumed  that  each  species  of  toxin  con- 
sists of  exactly  two  equal  parts  of  dill'er- 
ent  character,  which  have  the  same  rela- 
tion to  the  antitoxin,  but  differ  in  their 
destructive  influence.  They  probably 
differ  from  each  other  like  dextrorota- 
tory and  levorotatory  substances.  4.  One 
of  these  constituents  is  called  x-modiflca- 
tion,  and  this  is  readily  transformed  in 


DIPHTHERIA.    PATHOLOGY. 


631 


all  toxins  into  to.\oids.  This  transfor- 
mation begins  already  in  the  incubator. 
Owing  to  the  disappearance  of  one-half 
of  the  poison,  the  complete  raetamorpho- 
sis  into  to.xoid  causes  a  semivalent  toxin 
to  remain,  called  hoemato.xin.  5.  The  sec- 
ond modification,  beta-modification,  is  in 
the  different  species  of  poisons,  prototox- 
ins,  deutcrotoxins,  and  tritotoxins  of 
variable  permanency.  The  beta-modiii- 
cation  of  the  deuteroto.xins  ia  the  most 
stable.  This  explains  the  fact  that  after 
a  time  diphtheria-bouillon  reaches  a 
stage  of  definite  toxicity  that  is  perma- 
nent; whence  only  those  poisons  that 
have  entered  this  state  should  be  used 
as  diseased  toxins.  G.  In  the  change  of 
toxin  into  toxoid  the  affinity  of  the  anti- 
toxin is  not  in  the  least  modified,  and 
the  toxoid  of  the  prototoxin,  for  example, 
binds  the  antitoxin  in  the  same  way  as 
the  prototoxin  itself  does.  The  varieties 
of  poisons  combining  less  promptly  with 
the  antitoxin  are  less  readily  destroyed 
by  the  latter  than  those  that  combine 
with  it  more  promptly.  7.  Regarding  the 
significance  of  the  Lq  and  the  L-t-  dose, 
it  is  to  be  noted  that  the  Lo  dose  is  sub- 
ject to  greater  variation  than  the  h  + 
dose.  8.  The  facts  developed  are  best  ex- 
plained by  assuming  that  in  the  toxin- 
molecule  two  independent  atom-com- 
plexes are  present.  One  of  these  is  hap- 
tophorous,  which  causes  the  binding  of 
the  antitoxin  to  the  corresponding  lateral 
chain  of  the  cells.  The  other  is  tox- 
ophorous;  I.e.,  the  cause  of  the  specific 
action.  The  same  is  true  of  the  toxons. 
9.  The  haptophorous  group  is  responsible 
for  the  combination  of  the  toxin-mole- 
cule with  the  cells  and  thus  of  render- 
ing the  latter  amenable  to  the  influence 
of  the  toxophorous  group.  10.  The 
effects  of  the  haptophorous  and  tox- 
ophorous groups  can  in  certain  cases  be 
separated  experimentally.  Morgenroth 
has  shown  that  the  nen-ous  system  of 
the  frog  fixes  tetanus-poison  in  the  cold; 
disease-phenomena  do  not  arise  under 
these  circumstances.  If  the  frogs,  which 
have  been  treated  at  proper  intervals, 
first  with  poison  and  then  with  anti- 
toxin, are  placed  in  the  incubator,  tet- 
anus develops  even  when  all  the  circu- 
lating   poison    has    combined    with    the 


antitoxin,  and  even  when  the  latter  is 
present  in  excess.  The  haptophorous 
group  thus  acts  already  in  the  cold,  the 
toxophorous  only  after  the  application 
of  heat.  11.  The  temporal  difference  in 
the  action  of  the  haptophorous  and  tox- 
ophorous groups  explains  also  the  incu- 
bation period.  12.  The  toxophorous  group 
is  iiioie  complicated  and  less  permanent 
than  the  haptophorous.  The  anti-bodies 
produced  by  the  influence  of  the  poison 
act  exclusively  on  the  haptophorous 
group.  By  combining,  through  the  medi- 
ation of  this  haptophorous  group,  with 
the  entire  toxin-molecule,  they  prevent 
the  toxophorous  group  from  acting  upon, 
the  organs.  13.  The  specific  antitoxin 
can  also  be  produced  with  toxoids,  but 
the  immunity  cannot  be  used  to  procure 
curative  serum.  The  toxons  probably 
play  an  important  rule:  In  natural  im- 
munity, i.e.,  in  the  form  in  which,  not 
the  poisons  isolated,  but  the  causative 
agents  themselves  are  the  factors.  Tox- 
oids are  decomposition-products  of  the 
prepared  toxin.  14.  It  is  probable  that 
prototoxins  also  are,  under  certain  cir- 
cumstances, capable  of  bringing  about  a 
direct  cure,  by  displacing  the  poison 
from  the  tissue-elements  by  reason  of 
their  stronger  affinity  for  the  latter. 
Paul  Ehrlich  (Deiit.  med.  Woch.,  Sept. 
22,  '98). 

Catarrhal  Diphtheria.  —  As  we 
have  already  seen,  the  local  effects  of  a 
diphtheritic  inflammation  vary  greatly. 
In  catarrhal  diphtheria  we  see  simply 
redness  and  some  swelling  of  the  mucous 
membrane  of  nose,  throat,  tonsils,  or 
larynx,  usually  with  an  increased  secre- 
tion of  the  mucous  glands.  Xone  of 
these  would  show  macroscopically  in  the 
rare  cases,  when  death  follows  such  a 
process.  Oertel  has,  however,  found  in 
these  cases  degeneration  of  *he  epithelial 
cells  of  the  mucous  membranes  similar 
to  those  seen  in  pronounced  cases  of 
diphtheria. 

The  DirnTHERiTic  Membrane. — The 
membrane  is  most  frequently  seen  upon 
the  tonsils,  soft  palate,  uvula,  phar}Tix, 


532 


DIPHTHEEIA.    PATHOLOGY. 


nares,  larynx,  trachea,  or  bronchi.  lu 
scTere  cases  it  may  appear  upon  the  lips, 
especially  at  the  angles  of  the  mouth, 
the  buccal  mucous  membrane,  and  the 
tongue.  Very  rarely  it  appears  in  the 
oesophagus,  stomach,  or  intestines.  In 
fact,  the  freedom  of  the  cesophagus,  when 
the  diphtheritic  membrane  may  be  seen 
completely  covering  the  pharjTix  and 
tonsils  and  extending  throughout  the 
whole  respiratory  tract  even  to  the  ter- 
minal bronclii,  is  most  remarkable.  Even 
in  the  severest  cases  the  membrane  usu- 
ally stops  abruptly  at  the  beginning  of 
the  oesophagus. 

It  is  also  possible  to  observe  a  true 
diphtheritic  membrane  upon  abraded 
cutaneous  surfaces;  upon  woimds,  as  in 
tracheotomy;  or  upon  the  conjunctiva 
or  the  genital  mucous  membrane.  The 
color  of  the  membrane  may  be  white, 
gray,  greenish  white,  yellow,  or  more  or 
less  black,  when  there  has  been  hsemor- 
rhage  from  the  affected  surfaces.  It  may 
be  thick  and  elastic,  so  as  to  be  stripped 
off  in  sheets,  or  thin  and  diffluent.  The 
thicker  membrane  is  observed  iipon  the 
surfaces  covered  with  columnar  epithe- 
lium, with  a  definite  basement-mem- 
brane, such  as  the  nose,  larynx,  trachea, 
and  bronchi.  Here,  too,  it  is  but  loosely 
attached;  so  that  it  is  often  thrown  off 
in  casts  during  life,  or  after  death  may 
easily  be  stripped  off  from  the  under- 
lying surfaces.  Upon  the  tonsils, 
pharynx,  uvula,  and  fauces,  where  the 
epithelium  is  of  the  squamous  variety 
and  without  a  basement-membrane,  the 
diphtheritic  membrane  is  much  more 
closely  attached.  Often  in  these  situa- 
tions we  see,  after  death,  no  distinct 
membrane,  but  a  diffluent  exudate,  which 
may  be  easily  washed  off,  leaving  a  dis- 
tinctly-ulcerated surface  beneath. 

Microscopically  the  membrane  or  exu- 
date is  found  to  consist  chiefly  of  fibrin. 


mingled  with  epithelial  cells  from  the 
mucous  membrane,  pus-cells,  red  blood- 
cells,  granular  material,  and  bacteria. 
The  superficial  parts  of  the  membrane 
are  granular  in  character,  while  beneath 
we  find  a  more  or  less  distinct  net-work 
of  fibrin,  inclosing  within  its  meshes  the 
cells,  granular  material,  and  bacteria. 
The  bacteria  are  the  diphtheria  bacilli 
together  with  streptococci  or  staphylo- 
cocci, and  rarely  pneumococci.  The  in- 
flammatory process  may  be  superficial  or 
may  extend  irregularly  into  the  mucous 
membrane,  in  some  cases  involving  the 
submucous  tissue  and  even  the  muscular 
coat.  The  bacteria  may  likewise  pene- 
trate deeply  into  the  tissues,  but  are 
usually  most  abundant  in  the  superficial 
parts  of  the  membrane.  The  epithelial 
cells  of  the  mucous  membrane  undergo 
degeneration,  their  protoplasm  becoming 
granular,  their  nuclei  fragmented,  and 
the  cells  ultimately  breaking  up  into 
granular  material.  The  pathological 
process  is,  therefore,  a  coagulation-ne- 
crosis involving  the  mucous  membrane 
more  or  less  deeply. 

The  pseudomembrane  is  cast  off  in 
masses  or  is  gradually  disintegrated,  with 
more  or  less  destruction  of  the  mucous 
membrane.  The  process  of  separation  is 
usually  attended  by  a  more  abundant 
cellular  exudation  beneath  the  pseudo- 
membrane.  Except  in  the  gangrenous 
cases  apart  from  the  tonsil,  in  which 
there  may  be  extensive  destruction  of 
the  tissues,  the  integrity  of  the  mucous 
membrane  is  completely  restored,  leav- 
ing no  traces  of  the  preceding  disease. 
Gangrene  is  not  properly  a  part  of  the 
diphtheritic  process,  but  is  brought  about 
either  by  especially-unfavorable  condi- 
tions affecting  the  vitality  of  the  patient 
and  by  the  invasion  of  unusually-virulent 
bacteria  other  than  the  diphtheria  ba- 
cilli, probably  the  streptococci. 


DIPHTHERIA.    PATHOLOGY. 


533 


The  seat  and  distribution  of  the  mem- 
brane vary  greatly  in  different  cases.  The 
point  of  importance  with  reference  both 
to  symptoms  and  prognosis  is  the  involve- 
ment of  the  larynx.  Of  1000  cases  ana- 
lyzed by  Lennox  Browne,  the  larynx  was 
involved  in  159,  in  only  4  of  which  num- 
ber was  the  affection  limited  to  the 
larynx.  In  a  similar  analysis  of  109 
cases  by  Holt,  the  larynx  suffered  in  4G, 
in  10  of  which  the  disease  involved  either 
the  larynx,  or  the  larynx  with  the  trachea 
or  bronchi.  Holt  gives  no  purely  nasal 
cases  in  his  series;  2  are  given  by  Bro^vne. 
In  the  great  majority  of  cases  the  mem- 
brane is  found  upon  the  tonsils  or  the 
adjacent  parts,  the  pharynx,  uvula,  and 
pillars  of  the  fauces.  Six  hundred  and 
seventy-two  of  Browne's  1000  cases 
showed  such  distribution. 

Since  extension  of  the  membrane 
usually  increases  the  severity  of  the  case 
and  the  probability  of  death,  the  clinical 
records  of  Browne  show  the  comparative 
frequency  of  the  various  forms  better 
than  tables  which  are  largely  formed 
from  autopsy  records.  Laryngeal  cases 
are  also  much  more  frequently  met  with 
in  children's  hospitals  or  asylums  than 
in  dispensary  or  private  practice. 

In  cases  involving  the  nasal  cavities 
the  process  is  often  catarrhal,  and  there 
may  be  no  macroscopical  lesion  after 
death.  In  many  such  cases,  however, 
there  may  be  membrane  in  the  rhino- 
pharynx,  the  adenoid  tissue  of  the  vault 
of  the  pharynx  being  a  favorite  seat  of 
the  disease.  When  membrane  is  devel- 
oped in  the  nose,  it  is  usually  thick  and 
but  loosely  attached;  so  that  it  may 
readily  be  thrown  off  as  casts  of  the 
nares. 

LTpon  the  tonsils  the  membrane  may 
be  found  only  in  the  crypts,  resembling 
a  follicular  tonsillitis,  or  it  may  be  in 
scattered    patches,    or    may    completnly 


cover  the  surface.  It  is  closely  adherent. 
The  tonsils  are  swelled  and  may  even 
meet  in  the  median  line.  In  most  cases 
the  membrane  spreads  to  the  surround- 
ing jjarts:  the  phar^-ngeal  walls,  the 
fauces,  or  uvula.  The  epiglottis  is  also 
frequently  involved  in  these  cases,  even 
when  the  larynx  is  not  affected.  The 
membrane  often  extends  into  the  rhino- 
pharjTix  and  thence  may  pass  to  the 
Eustachian  tubes  and  the  middle  ear. 
Upon  the  uvula  or  fauces  the  membrane 
is  usually  thicker  and  more  loosely  at- 
tached than  that  upon  the  tonsils. 

The  uvula  is  swelled  and  cedematous. 
The  epiglottis,  if  involved,  is  swelled  and 
thickened  and  one  or  both  surfaces  may 
be  covered  with  membrane.  After  death 
the  membrane  upon  these  parts  does  not 
show  as  clearly  as  during  life,  and  we  are 
apt  to  find  a  more  or  less  marked  ulcera- 
tion of  the  parts.  The  epiglottis  fre- 
quently shows  considerable  destruction 
of  the  mucous  membrane.  Microscopic- 
ally the  pathological  process  may  extend 
deeply  into  the  submucous  or  even  the 
muscular  coats  of  these  parts,  but  the 
ulceration  rarely  extends  beyond  the 
superficial  epithelium.  In  cases  where 
the  membrane  appears  upon  the  pharjTi- 
geal  walls  it  will  be  found  to  stop  short 
at  the  level  of  the  cricoid  cartilage,  the 
esophagus  being  perfectly  normal. 

The  appearances  in  the  larynx  are 
quite  different  from  those  met  with  in 
the  throat.  The  laryngeal  process  may 
be  simply  catarrhal,  even  when  there  is 
abundant  membrane  in  the  throat  and 
there  have  been  marked  laryngeal  symp- 
toms; so  that  the  larynx  after  death  may 
appear  normal,  or  there  may  be  a  slight 
congestion  of  the  mucous  membrane  and 
the  vocal  cords  after  death.  In  other 
cases  we  see  a  finely-granular  deposit 
upon  the  cords  and  mucous  membrane, 
and  the  ventricles  of  the  larvnx  niav  he 


534 


DIPHTHEKIA.    PATHOLOGY. 


filled  by  a  yelloTrish-white  exudate,  but 
there  is  no  distinct  membrane.  Again 
we  may  see  a  distinct  membrane  mask- 
ing the  cords,  obliterating  the  ventricles, 
and  covering  the  mucous  membrane  be- 
low. When  there  is  either  exudate  or 
pseudomembrane  present  in  the  larj-nx, 
it  is  rarely  limited  to  that  part,  but  will 
be  found  to  extend  into  the  trachea  and 


bronchi,  and  even  the  lungs.  In  the 
trachea  we  may  see  scattered  areas  of 
membrane,  or  the  membrane  may  line 
the  whole  extent  of  the  respiratory  tract. 
There  is  usually  a  much  more  distinct 
membrane  in  the  trachea  than  in  the 
larjTix  itself.  Upon  these  surfaces  the 
membrane  is  but  loosely  attached;  so 
that  it  may  be  coughed  up  in  complete 


% 

■:■>>'.:''               -A<y  ^"' iHPBWB 

1 

U^HlHi^^^ 

./  , 

^H^^r^^^^^^^SH^^I 

I 

Diphtheria  of  tonbila,  larj'nx,  tracliea,  and  bronchi.  At  upper  end  the  tonsils  and  base 
of  tonffuc  are  seen.  The  tonsils  showed  superfieiul  ulceration,  covered  by  thin 
membrane.  Epiglottis  is  thickened.  Kiglit  ventricle  of  larynx  filled  by  exudate 
and  obliterated.  From  left  vocal  cord  hang  some  shreds  of  membrane.  Immedi- 
ately below  vocal  cords  membrane  completely  covers  larynx  and  trachea.  Lifted 
on  the  skewers  it  contracts  to  a  rope-like  strand,  which  is  seen  extending  to  finest 
bronchi  on  right  side.    Both  lower  lobes  of  lungs  consolidated  by  pneumonia. 


DIPHTHERIA.    PATHOLOGY. 


535 


casts  of  the  bronchial  tree,  or  after  death 
may  be  readily  lifted  from  the  under- 
lying tissues  (see  illustration). 

In  a  series  of  autopsies  upon  87  cases 
of  laryngeal  diphtheria  made  by  one  of 
us  (Northrup)  the  distribution  of  the 
membrane  was  given  as  follows:  In  9 
cases  the  membrane  extended  from  the 
tip  of  the  nose  to  the  finest  bronchi;  in 
6  from  the  nose  to  the  bifurcation  of  the 
trachea;  in  17  from  the  pharynx  to  the 
finest  bronchi;  in  17  from  the  larynx 
to  the  finest  bronchi;  in  17  from  the 
pharynx  to  the  main  bronchi;  in  17  in 
the  larynx  and  trachea;  in  3  in  the 
pharynx  and  larynx;  and  in  1  in  the 
larynx  only.  This  work  was  done  in  the 
preantitoxin  days,  and  it  must  be  said 
that  in  the  autopsies  made  since  the 
introduction  of  antitoxin  such  extensive 
distribution  of  membrane  is  but  rarely 
met  with. 

Pseudomembrane  may  be  found  in 
the  stomach  or  intestines,  but  is  rarely, 
if  ever,  produced  in  these  situations  by 
the  action  of  the  diphtheria  bacillus; 
streptococci  are  usually  found.  Occur- 
ring upon  the  conjunctiva,  the  lips,  buc- 
cal mucous  membrane,  or  the  tongue,  the 
diphtheritic  membrane  does  not  present 
any  unusual  features. 

Case  of  diphtheritic  stomatitis  observed 
in  a  child  of  4  years,  who  for  several 
days  had  suffered  with  slight  pseudomem- 
branous stomatitis  represented  by  three 
small  patches  on  the  end  of  the  tongue. 
The  condition  proving  rebellious  to  local 
treatment,  bacteriological  examination 
was  made,  and  almcst  pure  cultures  of 
Klebs-Loefller  bacillus  were  obtained. 
Under  the  influence  of  20  centimetres  of 
antitoxin  the  case  yielded  in  four  days, 
the  pseudomembrane  coming  away  just 
as  in  pharyngeal  cases.  Jlongour  (Treat- 
ment, Apr.  14,  '9S). 

Upon  abraded  skin  surfaces  or  upon 
wounds,  —  especially  the  tracheotomy 
wound   in   laryngeal   cases, — the   mem- 


brane may  be  pronounced,  and  is  usu- 
ally reproduced  with  remarkable  rapid- 
ity after  removal. 

Case  of  diphtheria  of  the  umbilicus 
observed  in  a  child  14  days  old.  The 
Klebs-Loefller  bacillus  was  found  in  the 
pus  from  the  umbilicus.  The  child 
gradually  weakened  and  died  within  two 
days.  Examination  after  death  showed 
larynx  and  pharynx  normal.  The  local 
lesion  had  not  extended  to  other  organs. 
Bernard  Pitts  (Lancet,  Apr.  3,  '97). 

In  puei-peral  infection  in  most  in- 
stances the  streptococcus  pyogenes  is 
found  to  be  the  morbific  agent,  but  it  is, 
however,  not  infrequent  for  the  Klebs- 
Loefller  bacillus  to  be  discovered  in  the 
discharge  from  the  uterus;  and  in  these 
cases  it  is  probably  the  source  of  infec- 
tion. Longyear  (Amer.  Jour,  of  Obst., 
Oct., '97). 

Two  cases  of  diphtheria  in  the  vulva. 
Diphtheria  of  the  ^-ulva  may  occur  pri- 
marily, or  secondarily  with  clinical  and 
bacteriological  diphtheria  of  the  throat. 
W.  P.  Coues  (Boston  Med.  and  Surg. 
Jour.,  May  12,  '98). 

Apart  from  the  lesions  produced  by 
the  diphtheria  bacilli  at  or  by  extension 
from  the  site  of  inoculation,  they  appear 
to  produce  no  other  direct  effects,  al- 
though they  may  be  found  present  in 
the  viscera.  Their  toxins,  on  the  other 
hand,  produce  definite  and  character- 
istic visceral  lesions.  The  experimental 
work  of  Welch  and  Flexner,  Abbott,  and 
others  has  served  to  make  known  these 
remote  effects  of  the  toxins.  In  the  great 
majority  of  cases  of  human  diphtheria, 
other  bacteria,  especially  streptococci,  are 
present  and  active  besides  the  specific 
bacilli;  they  are  mixed  infections,  and 
the  problem  of  determining  the  action 
of  any  one  organism  is  greatly  compli- 
cated. In  forty-two  autopsies  in  cases 
of  diphtheria  in  which  the  Loeffler  ba- 
cillus had  been  demonstrated  during  life, 
Eeiche  is  reported  to  have  found  strepto- 
cocci and  staphylococci  in  the  kidney  or 
spleen,  and  streptococci  alone  in  45.2  per 


536 


DIPHTHERIA.    PATHOLOGY. 


cent.  Streptococci  vrere  found  in  the 
kidney  in  one  case  ■whicli  died  on  the 
second  day,  and  positive  results  were  also 
obtained  on  the  third  and  fourth  days. 
The  results  obtained  by  experimental  in- 
oculation of  the  toxins  in  susceptible 
animals  are,  therefore,  much  simpler  and 
more  easily  interpreted  than  examina- 
tions of  the  viscera  of  fatal  cases  of 
human  diphtheria.  The  lesions  produced 
by  the  toxins  are  found  in  the  lymph- 
nodes,  liver,  kidney,  spleen,  heart- 
muscle,  the  peripheral  nerves,  and  lungs. 

The  red  corpuscles  of  the  blood  in 
diphtheria  undergo  a  diminution  in  num- 
ber in  cases  of  moderate  severity  and  in 
severe  cases.     Regeneration  is  slow. 

The  leucocytes  are  increased  in  num- 
ber in  all  but  two  classes  of  cases:  ex- 
ceptionally-mild cases  and  exceptionally- 
severe  ones.  As  a  rule,  the  amount  of 
leucocytosis  is  directly  proportionate  to 
the  degree  of  severity  of  the  case.  The 
leucocyte-curve  shows  no  correspondence 
to  the  clinical  course  of  the  disease.  The 
leucocytosis  is  similar  in  character  to 
that  seen  in  pneumonia  and  scarlet  fever, 
the  increase  being  in  the  so-called  poly- 
nuclear  forms. 

The  percentage  of  hfemoglobin  falls 
coincidently  with  the  number  of  the  red 
corpuscles  and  to  the  same  relative  de- 
gree. But  the  regeneration  of  the  hEemo- 
globin  takes  place  much  more  slowly 
than  that  of  the  red  corpuscles. 

In  cases  treated  with  antitoxin  the 
diminution  in  number  of  the  red  cor- 
puscles is  much  less  marked  than  in  those 
cases  treated  without  it;  in  a  majority  of 
tlie  cases  no  such  diminution  takes  place. 
The  leucocytes  are  apparently  unaffected 
by  the  antitoxin.  The  hemoglobin  is 
also  much  less  affected  in  the  cases 
treated  with  antitoxin,  thus  confirming 
the  statement  as  to  the  red  corpuscles. 

In  healthy  subjects  injected  with  anti- 
toxin the  red  corpuscles  show  a  very 
moderate  reduction  in  number  in  about 
one-half  the  cases.  The  hnemoglobin  is 
correspondingly  affected.  The  leucocytes 
arc  apparently  unaffected  by  the  injec- 
tions. 


It  is  improbable  that  any  information 
of  prognostic  importance  is  to  be  gained 
by  examination  of  the  blood  in  diph- 
theria. J.  S.  Billings,  Jr.  (Med.  Record, 
Apr.  2G,  '96). 

The  blood  in  2-1  children  suffering  from 
diphtheria  examined  with  a  view  to  de- 
termining the  effects  of  antitoxic  serum. 
In  21  cases,  when  examined  before  the 
injections,  a  manifest  hyperleucocytosis 
was  found,  the  degree  of  which  varied 
between  1  to  71  and  1  to  275.  This  leu- 
cocytosis was  not  in  relation  with  either 
the  age  of  the  child  or  the  elevation  of 
temperature  presented  at  the  moment  of 
the  examination;  the  inlluence  of  the 
gravity  of  the  affection  upon  the  leuco- 
cytosis was  not  constant,  but,  in  gen- 
eral, the  degree  of  hyperleucocytosis  was 
more  marked  the  graver  the  case.  Hy- 
perleucocytosis diminished  as  the  case 
proceeded  to  recovery,  but  persisted  in 
the  cases  terminating  in  death. 

The  influence  of  an  injection  of  serum 
was  manifested  at  first  by  a  diminution 
of  hyperleucocytosis,  followed  at  the  end 
of  some  time  by  an  increase  in  the  num- 
ber of  leucocytes,  which  did  not  always 
attain  the  degree  observed  before  the  in- 
jection. Schlesinger  (Archiv  f.  Kinderh., 
B.  19,  S.  378,  '96). 

Welch  and  Flexner  have  shown  that 
these  visceral  lesions  are  produced  either 
by  injections  of  pure  cultures  of  the 
diphtheria  bacillus  or  by  inoculation  of 
their  toxins. 

The  lymph-nodes — cervical,  bronchial, 
mesenteric,  axillary,  and  inguinal — are 
found  to  be  swelled.  There  are  haemor- 
rhages either  beneath  the  capsule  or  into 
the  substance  of  the  glands.  The  cells 
show  more  or  less  advanced  degenera- 
tive changes  both  in  their  nuclei  and  in 
the  cell-protoplasm.  The  nuclei  arc  frag- 
mented; the  cell-bodies  are  converted 
into  a  finely-granular,  reticulated  ma- 
terial, apparently  fibrinous.  Similar 
changes  are  observed  throughout  the 
lymph-structures  of  the  body,  Peyer's 
patches,  solitary  and  agminate  folli- 
cles of  the  intestines,  etc.    The  changes 


DIPHTHERIA.    PATHOLOGY. 


537 


in  the  lymph-nodes  rarely  lead  to  suppu- 
ration. 

The  spleen  is  swelled  and  usually  soft- 
ened. There  may  be  hremorrhages  be- 
neath the  capsule  or  into  the  substance 
of  the  organ.  The  follicles  are  enlarged 
and  the  cells  show  degenerative  changes 
simil^  to  those  seen  in  the  lymph-nodes. 
The  liver  shows  haBmorrhages  either 
upon  its  surface  or  within  its  substance. 
There  may  be  an  advanced  fatty  degen- 
eration of  the  liver.  There  are  also  found 
minute  areas  in  which  there  has  been 
produced  a  necrosis  of  the  liver-cells,  the 
nuclei  being  fragmented  or  having  com- 
pletely disappeared,  while  the  bodies  of 
the  cells  show  advanced  degenerative 
changes.  Some  of  these  areas  are  infil- 
trated by  leucoc3'tes.  Similar  focpl  ne- 
croses in  the  liver  have  been  observed 
by  other  poisons  than  the  toxins  of  diph- 
theria. 

The  changes  in  the  kidney  include  a 
degeneration  of  the  epithelium  of  the 
tubes  and  glomeruli  and  hj-aline  altera- 
tion of  the  glomerular  capillaries  and 
smaller  arteries.  The  severe  affections  of 
the  kidney,  acute  exudative  or  diffuse 
nephritis,  met  with  as  complications  of 
the  later  stages  of  the  disease,  are  attrib- 
utable rather  to  the  accompanying  strep- 
tococcus infection  than  to  the  diphtheria 
itself. 

The  heart  shows  a  fatty  degeneration 
of  its  muscles,  sometimes  so  advanced  as 
to  produce  changes  in  every  fibre.  The 
nuclei  of  the  muscles  may  also  be  frag- 
mented. 

The  changes  produced  in  the  brain- 
cells  of  animals  inoculated  with  diph- 
theria toxins  have  recently  been  made 
the  subject  of  study  (Carlo  Ceni;  Berk- 
ley). Swelling  of  the  processes  of  cer- 
tain cells  of  the  brain  with  some  minor 
changes  in  the  conformation  of  the  cells, 
but  without  evidence  of  defeneration  of 


the  cells  or  their  processes,  was  observed. 
The  cerebral  were  more  affected  than 
the  cerebellar  cells. 

Various  lesions  have  been  found  in  the 
spinal  cord  in  cases  of  diphtheritic  pa- 
ralysis, but  none  of  the  changes  observed 
in  the  cord  have  thus  far  been  accepted 
as  the  explanation  of  the  paralysis. 

Katz  has  recently  reported  finding, 
after  careful  examination  of  the  cords  of 
three  fatal  cases,  distinct  changes  in  the 
motor  ganglion  cells  of  the  anterior 
horns  of  the  cord.  The  changes  were 
either  a  fatty  degeneration  affecting  the 
cells  or  complete  death  of  the  cells  with 
all  processes,  and  especially  the  axis-cyl- 
inder. All  ganglion  cells  of  the  cord 
were  similarly  affected,  but  not  so 
markedly  as  the  motor  cells  of  the  an- 
terior horns. 

The  changes  in  the  peripheral  nerves, 
on  the  other  hand,  are  looked  upon  by 
some  as  the  most  characteristic  patho- 
logical lesion  of  diphtheria.  The  affected 
nerves  are  sometimes  red  and  swelled, 
from  congestion  and  oedema,  but  the 
degeneration  of  the  nerve-fibres  is  the 
characteristic  feature  of  the  process. 
Single  nerve-fibres  or  a  whole  nerve- 
trunk  may  be  affected.  The  changes  may 
be  either  interstitial  or  parenchymatous. 
In  the  parench}Tnatous  form  there  is  usu- 
ally a  more  or  less  marked  infiltration 
of  leucocj'tes  within  the  nerve-sheath,  be- 
tween the  sheath  and  the  nerve-fibres, 
or  between  the  fibres  themselves.  The 
medullary  sheath  of  the  nerve-fibre  is 
swelled,  undergoes  a  fatty  degeneration, 
and  may  altogether  disappear.  The  axis- 
cylinder  undergoes  a  similar  degenera- 
tion; it  may  be  changed  to  a  granular 
mass  and  be  completely  absorbed.  The 
empty  sheaths  of  Schwann  may  be  the 
only  evidence  left  of  the  former  nerve- 
fibre.  Sooner  or  later  the  degeneration 
stops;   regeneration  begins  and  usually 


538 


DIPHTHERIA.    PATHOLOGY. 


results  in  complete  restoration  of  the 
nerve-fibres.  In  the  interstitial  form  the 
increase  of  the  connective  tissue  of  the 
endoneurium  and  perineurium  is  the 
marked  feature  of  the  process.  In  some 
cases  the  changes  are  both  parenchjina- 
tous  and  interstitial. 

A  study  of  the  changes  in  the  nervous 
system  due  to  the  action  of  diphtheritic 
poison  shows:  1.  A  marked  parenchy- 
matous degeneration  of  the  peripheral 
nerves,  sometimes  accompanied  by  an 
interstitial  process  and  hyperremia  and 
hjemorrhages.  2.  Acute  diii"use  pai-enchy- 
matous  degeneration  of  the  nerve-fibres 
of  the  cord  and  brain.  3.  Xo  changes,  or 
but  slight  ones,  in  the  nerve-cells.  4. 
Acute  parenchymatous  and  interstitial 
changes  in  the  muscles,  especially  the 
heart-muscle.  5.  Occasional  hyperremia, 
or  infiltration,  or  hfemorrhage  in  the 
brain  or  cord,  in  rare  cases  severe  enough 
to  produce  permanent  troubles,  such  as 
the  cases  of  multiple  sclerosis  and  of 
hemiplegia  which  have  been  observed.  6. 
The  probability  that  the  cases  of  sudden 
death  from  heart-failure  in  diphtheria, 
during  the  disease  or  convalescence,  are 
due  to  the  effects  of  the  toxic  substances 
produced  in  the  disease  upon  the  nerve- 
structures  of  the  heart.  J.  J.  Thomas 
(Boston  Med.  and  Surg.  Jour.,  Feb.  10, 
'98). 

Four  cases  obser\-ed  in  which  the  diph- 
theria bacillus  was  found  in  the  blood 
and  in  the  nervous  centres.  In  one  case 
tlie  germs  had  entirely  disappeared  from 
the  throat,  but  were  found  in  pure  cult- 
ure in  the  bulbar  centres.  Paralysis  was 
ab.sent.  RichardiiJre  (La  Rev.  M6d.; 
Pediatrics,  May  1,  '98). 

Forty   per  cent,  of   the   post-diphthe- 
ritic palsies  are  confined  to  the  palate, 
and  in  12  per  cent,  the  palate  and  eye 
muscles  are  afTected.    The  pharynx  may 
be  the  only  part  involved,  or  it  may  be 
in   conjunction   with   other   parts,   near 
or  distant.     The  muscles  of  mastication 
are  very  rarely  involved.    Felt  (Medical 
News,  Feb.  14,  1903). 
The  pulmonary  changes  produced  by 
the  experimental  action  of  diphtheria  ba- 
cilli or  their  toxins  are  slight  and  of  no 


importance,  but  the  pulmonary  compli- 
cations of  clinical  diphtheria  are  fre- 
quent, severe,  and  of  great  moment. 
Wright,  More,  Kanthack,  Stephens, 
and  others  have  demonstrated  the  pres- 
ence of  diphtheria  bacilli  in  the  lungs 
in  fatal  cases  of  diphtheria,  but  the  pres- 
ence of  the  bacilli  apparently  has  but 
little  to  do  Tvith  the  production  of  pul- 
monary complications.  In  1SS9,  in  an 
investigation  of  a  series  of  seventeen 
cases  of  pneumonia  complicating  diph- 
theria, Prudden  and  Northrup  found 
streptococci  both  in  the  pseudomem- 
branes  in  the  throat  and  in  the  lungs.  It 
vras  further  shown  that  the  inoculation  of 
streptococci  in  stisceptible  animals  served 
to  produce  changes  in  the  lungs  similar  to 
those  seen  in  clinical  diphtheria.  These 
observations  have  been  fully  corrobo- 
rated, and  the  streptococci  are  accepted 
as  the  active  agents  in  the  production  of 
the  pneumonia  which  so  frequently  com- 
plicates diphtheria.  Broncho-pneumonia 
is  met  with  in  the  great  majority  of  fatal 
cases,  especially  in  hospital  practice.  In 
the  most  acute  cases  we  find  the  posterior 
parts  of  one  or  both  lungs  deeply  con- 
gested, firm  to  the  touch,  and  on  section 
showing  scattered  areas  of  peribronchial 
consolidation,  deep  red  in  color.  The 
lower  lobes  are  usually  more  affected  than 
the  upper.  In  the  slower  cases  we  find 
the  areas  of  pneumonia  scattered 
throughout  both  lungs,  but  affecting  the 
lower  and  posterior  portions  especially, 
the  consolidation  often  involving  a  large 
part  of  both  lungs  and  on  section  appear- 
ing mottled,  reddish-brown  and  yellow- 
ish-white. Pleurisy  and  empyema  are 
rarely  met  with.  In  laryngeal  cases  with 
marked  stenosis  there  is  usually  emphy- 
sema, both  vesicular  and  interstitial.  The 
interstitial  emphysema  may  involve  the 
cellular  tissues  of  the  neck  and  even 
extend  over  the  trunk. 


DIPHTHERIA.    PROGNOSIS. 


539 


Prognosis.  —  In  no  other  acute  in- 
fectious disease  is  the  prognosis  so  uncer- 
tain as  in  diphtheria.  !Many  factors  must 
be  taken  into  consideration  in  determin- 
ing the  prognosis  in  any  given  case. 

1.  Age  of  the  patient.  Happily  chil- 
dren wnder  six  months  of  age  are  rarely 
attacked;  but  between  that  age  and  two 
years  many  cases  are  seen,  and  the  mor- 
tality is  often  frightful.  With  increase 
in  age  the  mortality  falls  steadily,  but 
even  in  adult  life  diphtheria  may  readily 
prove  fatal. 

The  following  tables  taken  from  the 
article  of  Biggs  and  Guerard  in  "The 
Use  of  Antitoxic  Serum,"  show  the  favor- 
orable  influence  of  age  very  clearly: — 
Heiz:    Mortality  Percentage. 

O-I  year 8U.00 

1-3  years 45.00 

3-5  years 40.00 

5-10  years 17.00 

Over  10  years 17.00 

Hirsch:    Mortality  Percentage. 

0-1  year 83.3 

1-3  years S2.5 

3-4  years 63.9 

4-5  years 4G.9 

6-7  years 43.2 

Over  7  years 22.2 

Baginsky:    Mortality  Percentage. 

0-2  years 63.3 

2-4  years 52.8 

4-6  years 37.9 

0-10  j-ears 24.6 

10-15  years 14.0 

The  ratios  are  all  derived  from  cases 
treated  previous  to  the  introduction  of 
nntitoxin  or  without  its  use.  The  analy- 
sis of  a  large  number  of  cases  treated  by 
antitoxin,  while  the  mortality-ratios  are 
diminished,  shows  that  the  age  influence 
remains  practically  the  same. 

0-2  years 1494  4f.n  31.4 

2-0  years 3078  762  20.7 

5-10  years 31S4  473  14.8 

Over  10  years..  1444  99  0.9 


The  subcutaneous  injection  of  saline 
solution  in  a  child  with  diphtheria  may 
throw  light  on  the  prognosis.  If  after 
giving  the  injection,  the  child  voids  more 
urine  without  vomiting  or  diarrhoea,  the 
diphtheria  will  run  a  mild  course,  no 
matter  how  stormy  the  onset.  But  if 
the  amount  of  urine  is  not  increased, 
and  there  is  vomiting  or  diarrhoea,  the 
prognosis  is  grave,  as  the  toxins  have 
affected  the  heart-fibres,  and  the  organ 
is  thus  unable  to  respond  to  the  action 
of  the  saline  solution.  Rabot  (Bull. 
M6d.,  Sept.  4,  1901). 

2.  The  site  of  the  disease.  Involve- 
ment of  the  larynx  either  primarily  or 
secondarily  adds  greatly  to  the  danger 
of  the  case.  The  large  death-rate  under 
two  years  is  due,  in  great  part,  to  the 
strong  tendency  of  the  disease  to  invade 
the  larjTix  during  that  period. 

The  use  of  antitoxin  has  materially 
changed  all  the  figures  relating  to  the 
fatality  of  the  various  forms  of  diph- 
theria, but  the  laryngeal  process  remains 
the  most  deadly. 

Influence  of  antitoxin  on  the  death- 
rate  of  the  three  principal  Australian 
colonies.  In  Queensland  the  mean  an- 
nual death-rate  per  100,000  living  from 
1884  to  1889  was  42.9.  From  1890  to 
1894,  44.1;  from  1895  to  1898  (the  anti- 
toxin period),  14.4.  In  Xew  South  Wales 
the  mean  annual  death-rate  per  100,000 
living  from  1SS4  to  1889  was  43.2;  from 
1890  to  1894  it  was  47.7;  from  1895  to 
1898  (the  antitoxin  period),  18.4.  In 
Victoria  the  mean  annual  death-rate  per 
100,000  living  from  1884  to  1889  was 
45.4;  from  1890  to  1894.  39.8;  from  1895 
to  1898  (the  antitoxin  period),  19.7.  J. 
Turner  (Brit.  Med.  Jour.,  Nov.  18,  '99). 
There  has  been  a  decline  in  the  mor- 
tality of  diphtheria  in  Prussia  since  1894 
that  cannot  be  explained  by  the  improve- 
ment of  sanitary  conditions.  From  1885 
to  1894  the  death-rate  from  this  disease 
averaged  15.5  per  cent,  to  every  10,000 
of  the  population.  It  fell  in  1895  to  9 
per  cent,  and  in  1896  to  7.6  per  cent; 
in  1897  to  6.2  per  cent  This  points  to 
the   general    adoption    of   the   antitoxin 


540 


DIPHTHERIA.    PKOGIsOSIS. 


treatment  of  diphtheria  in  private  as 
well  as  hospital  practice.  A.  W.  Wil- 
loughby  (Therapist,  July,  '99). 

From  October  5,  1S95  (the  dat«  of  the 
first  administration  of  antitoxin  by  the 
department),  to  February  2S,  1S99,  a 
total  of  6343  reported  eases  of  diphtheria 
were  visited  by  the  Chicago  departmental 
inspectors.  Of  this  number  4311  were 
bacteriologically  verified  as  true  diph- 
theria, and  4076  treated  with  antitoxin. 
Kesults  show  3795  recoveries  out  of  the 
4076  cases  treated  by  the  department. 
There  were  276  deaths,  and  5  cases  were 
still  under  treatment  at  the  close  of  Feb- 
ruary, 1S99.  The  figures  of  recoveries, 
3795,  and  of  deaths,  276,  give  a  mor- 
tality-rate of  6.77  per  cent,  in  4071  cases 
of  bacteriologically  verified  diphtheria 
treated  with  antitoxin.  In  355  cases 
treated  on  the  first  day  of  the  disease 
there  was  only  1  death,  a  mortality  of 
only  0.28  per  cent.;  in  1018  cases  first 
treated  on  the  second  day  there  were  17 
deaths,  a  mortality  of  1.67  per  cent;  in 
1509  eases  first  treated  on  the  third  day 
there  were  57  deaths,  a  mortality  of  3.77 
per  cent.;  in  720  cases  first  treated  on 
the  fourth  day  there  were  82  deaths,  a 
mortality  of  11.39  per  cent.;  and  in  469 
cases  first  treated  later  than  the  fourth 
day  there  were  119  deaths,  a  mortality 
of  25.37  per  cent.  The  death-rate  of  0.77 
per  cent,  from  diphtheria  during  the  past 
tliree  years,  since  antitoxin  has  been 
used,  shows  a  decline  of  43  per  cent,  aa 
compared  with  that  for  the  previous  three 
years,  when  other  methods  of  treatment 
were  in  vogue.  (Bull,  of  Dept.  of  Health, 
Chicago,  Feb.,  '99;  Amer.  Jour.  Med. 
Sci.,  p.  86,  '99). 

Deaths  from  diphtheria  in  New  York 
have  declined  from  over  2000  in  1892  to 
1894,  to  1087  in  1898,  and  the  mortality 
from  30.7  per  cent,  in  1891,  and  40.0  per 
cent,  in  1892,  to  13.1  per  cent,  in  1899, 
and  12.2  per  cent,  in  1898.  Antitoxin 
was  given  free  of  charge  to  1902  patients 
in  1899,  with  a  mortality  of  12.3  per 
cent.,  or  with  91  moribund  eases  de- 
ducted 7.8  per  cent.;  1093  patients  were 
immunized  in  the  first  9  months  of  1899, 
and  among  these  only  6  cases  of  diph- 
theria occurred  after  twenty-four  hours 
and   within   thirty   days.     Fewer   caBe.s 


would  probably  have  occurred  after  im- 
munization if  300  units  instead  of  the 
usual  dose  of  150  units  had  been  given. 
Billings  (X.  Y.  Med.  Jour.,  Feb.  17, 
1900). 

Letter  sent  to  a  number  of  physicians, 
of  whom  673  replied.  Of  these,  622  were 
favorable  to  antitoxin,  26  expressed  no 
opinion,  and  only  5  were  opposed  to  it. 
The  total  number  of  cases  reported  was 
12,375,  the  recoveries  being  11,727,  a  per- 
centage mortality  of  5.23.  Correspond- 
ence with  health  officials  of  both  foreign 
and  American  cities  shows  the  mortality 
to  be  3S.4  per  cent,  in  183,256  cases  before 
the  antitoxin  period.  The  mortality  in 
132,548  cases  since  the  antitoxin  period 
was  14.6  per  cent.  Edwin  Rosenthal 
(Jour.  Amer.  Med.  Assoc,  Aug.  1,  1900). 

The  value  of  antitoxin  treatment  in 
diphtlieria  is  clearly  demonstrated  in 
the  returns  of  the  Metropolitan  Asy- 
lums Board.  In  1894,  3042  patients  of 
all  ages  were  treated  in  the  Board's  hos- 
pitals without  antitoxin ;  902  died,  yield- 
ing a  mortality  of  29.0  per  cent.  In  1895 
the  antitoxic  serum  treatment  was  in- 
augurated; 3529  cases  of  diphtheria 
were  treated,  and  729  died,  yielding  a 
mortality  of  22.5  per  cent.  Hence  in  the 
first  year  there  was  a  fall  in  mortality 
of  7.1  per  cent.  From  the  "Annual 
Report  of  the  Metropolitan  Asylums 
Board"  for  1901,  recently  issued,  it  ap- 
pears that,  in  1901,  6499  patients  sufl'er- 
ing  from  diphtheria  were  treated  with 
antitoxin  in  the  Board's  hospitals;  817 
died,  yielding  a  mortality  of  12.5  per 
cent.  There  has,  therefore,  been  a  fall 
in  mortality  percentage  from  29.0  in 
1894,  without  antitoxin,  to  12.5  in  1901, 
with  antitoxin.  In  other  respects  the 
treatment  has  been  substantially  the 
same.  The  laryngeal  cases  treated  in 
1901  with  antitoxin  numbered  753,  and 
there  were  159  deaths,  which  gives  a 
mortality  percentage  of  21.1.  It  has 
long  been  known  that  early  adminis- 
tration of  antitoxin  is  important  if  its 
real  advantages  are  to  be  gained.  But 
it  would  be  difficult  to  furnish  more 
concise  or  convincing  evidence  of  this 
well-known  fact  than  the  tables  printed 
in  the  Asylums  Board  Report  from  Dr. 
MncCombie's  results  at  the  Brook  Hoa- 


DIPHTHERIA.    PROGNOSIS. 


541 


pital.  During  the  year  723  cases  of 
diphtheria  were  treated  with  antitoxin, 
and  78  died,  yielding  a  mortality  per- 
centage of  10.79.  The  antitoxin  treat- 
ment was  applied  in  each  of  these  eases, 
but  in  some  it  was  possible  to  begin  on 
th?  first  day  of  the  disease,  in  others 
on  the  second,  and  so  on.  The  para- 
mount importance  of  administration  at 
the  earliest  possible  moment  is  seen  in 
the  result.  The  mortality  percentage  of 
the  first-day  cases  (38)  was  0.0;  of  the 
second  day  (170  cases),  4.1;  of  the  third 
day  (192  cases),  11.9;  of  the  fourth  day 
(137  cases),  12.4;  and  of  the  fifth  and 
subsequent  days  (186  cases),  IG.O.  For 
five  conseciitive  years  there  has  not  been 
a  death  at  this  hospital  among  the  cases 
that  came  under  treatment  on  the  first 
day  of  the  disease,  and  of  those  coming 
under  treatment  on  the  second  day  of 
the  disease  the  mortality  has  not  ex- 
ceeded 5.4  per  cent.  These  figures  af- 
ford striking  evidence  of  the  value  of 
antitoxin,  and  particularly  of  its  early 
administration.  Editorial  (Brit.  Med. 
Jour.,  March  14,  1903). 

3.  The  time  of  beginning  treatment. 
In  the  use  of  antitoxin  it  has  been 
demonstrated  beyond  the  shadow  of  a 
doubt  that,  the  earlier  the  remedy  is  em- 
ployed, the  surer  is  recovery,  while  after 
the  fifth  day  the  remedy  exerts  little  or 
no  influence.  It  has  always  been  clear 
that  delay  in  undertaking  treatment  led 
to  unfavorable  results,  but  the  vital  ne- 
cessity of  promptness  has  been  impressed 
upon  us  by  the  overpowering  evidence 
afforded  by  the  results  obtained  when 
antitoxin  is  resorted  to  early  in  the  case. 

4.  The  degree  of  toxismia.  This  feat- 
ure is  usually  developed  in  proportion 
to  the  lapse  of  time  from,  and  the  severity 
of,  the  onset  of  the  disease.  It  may  be 
slowly  or  rapidly  developed,  and  in  many 
cases  apparently  mild  in  the  beginning 
we  may  later  see  the  severest  types  of 
toxsemia. 

Conclusions  regarding  leucocytosis  in 
diphtheria:     1.  After  a  massive  dose  the 


number  of  polynuclear  leucocytes  de- 
scribes a  curve  of  parabolic  form,  with 
its  height  twelve  to  sixteen  hours  after 
the  inoculation,  and  increasing  rapidly 
and  regularly  until  death.  2.  In  slight 
intoxication  the  course  of  the  polynu- 
clears  is  represented  by  an  oscillatory 
curve.  3.  In  the  course  of  immunization 
leucocytic  reaction  is  very  manifest,  par- 
ticularly during  the  first  hours  after  the 
injection.  4.  Animals  which  have  been 
saved  by  antitoxic  serum  from  massive 
doses  of  toxin  show  the  same  oscillation 
in  the  polynuclear  leucocytes  as  in  mild 
cases  of  intoxication.  5.  Children  re- 
covering from  diphtheria  show  polynu- 
clear leucocytosis  lasting  from  twelve  to 
fifteen  days.  0.  If  the  course  of  the  dis- 
ease is  irregular,  or  if  phenomena  pre- 
venting a  cure  supervene,  the  blood 
shows  a  decided  correlation  between 
polynuclear  leucocytosis  and  the  gravity 
of  the  disease.  7.  Cases  going  on  to  a 
fatal  termination  in  spite  of  serum  show 
the  characteristic  polynuclear  leucocyto- 
sis. The  degree  of  polynuclear  leucocy- 
tosis after  the  injection  of  antitoxic 
serum  constitutes  one  of  the  surest  ele- 
ments of  prognosis  in  diphtheria.  Bes- 
redka  (Ann.  de  I'lnstitut  Pasteur,  May, 
•98). 

Researches  made  on  the  blood  of  26 
patients  suflering  from  diphtheria;  their 
ages  varied  from  five  and  one-half 
months  to  eight  years;  24  of  them  had 
the  fibrinous  form  and  2  only  had  the 
phlegmonous,  and  they  all  recovered. 
Obser\-ations  were  always  made  in  the 
evening  at  the  same  hour,  and  always 
from  three  to  four  hours  after  the  injec- 
tions, when  these  were  being  given.  In 
all  the  cases  leucocytosis  was  present  in 
greater  to  less  degree,  and  without  relar 
tion  to  the  temperature  and  age  of  the 
patient;  neither  was  it  possible  to  dis- 
cover a  constant  relation  between  the  in- 
tensity of  the  morbid  process  and  the 
leucocytosis.  The  leucocytosis,  however, 
increased  with  the  increase  of  the  mal- 
ady, and  only  began  to  decrease  after 
the  complete  absorption  of  the  exudate. 
The  injection  of  antidiphtheritic  serum 
caused  an  increase  in  the  leucocytosis. 
Antonio  Marioltini  (Pediatrin,  Aug., 
'99). 


5i3 


DIPHTHERIA.    PROGNOSIS. 


5.  The  extent  of  the  membrane  and 
the  rapidity  of  the  extension. 

6.  The  presence  of  complications,  es- 
pecially from  broncho-pneiunonia  or 
nephritis.  The  pneumonia  of  diphtheria 
is  by  far  the  most  important  of  the  com- 
plications. 

The  late  onset  of  the  cardiac  compli- 
cations of  diphtheria  is  to  be  remem- 
bered. Xo  case  of  severe  diphtheria  can 
be  considered  altogether  out  of  danger 
for  some  weeks  after  apparent  recovery. 

7.  The  surroundings  of  the  patient. 
The  mortality  of  diphtheria  is  consider- 
ably greater  in  hospitals  or  asylums  for 
children  than  in  private  or  dispensary 
practice.  The  crowding  of  the  children 
together  seems  to  exert  a  very  unfavor- 
able influence  by  exposing  them  to 
danger  from  complications,  and  most  es- 
pecially to  pneumonia. 

S.  The  mortality  of  diphtheria  may 
vary  greatly  from  year  to  year  in  the 
same  place  or  in  different  epidemics,  the 
causes  of  the  variation  not  being  appar- 
ent. Such  variations  in  the  type  of  the 
disease  may  properly  be  taken  into  ac- 
count in  the  prognosis  of  individual  cases. 

The  author  turns  to  the  figures  of  the 
committee  of  the  American  Paediatric 
Society,  embracing  5576  cases  of  diph- 
theria (moribund  cases  excluded),  col- 
lected principally  from  the  private  prac- 
tice of  American  physicians,  including 
two  rather  short  scries  from  the  hos- 
pitals of  New  York  and  Chicago.  The 
mortality  was  8.8  per  cent. 

Cases  injected  upon  the  first  day  gave 
a  death-rate  of  4.9  per  cent.;  upon  the 
second  day,  8.6  per  cent.;  upon  the  third 
day,  12.7  per  cent.;  upon  the  fourth 
day,  22.9  per  cent.;  and  after  the  fourth 
day,  38  per  cent.  The  result  of  this 
report  compares  favorably  with  any 
that  has  been  published  in  this  country 
or  in  Europe. 

To  illustrate  the  importance  of  the 
need  of  the  early  administration  of  the 
antitoxin,   Baginsky's   figures   are   even 


more  striking.  Cases  injected  upon  the 
first  day  give  a  death-rate  of  from  1.07 
per  cent,  to  2.7  per  cent.  Cases  injected 
upon  the  second  day  give  a  mortality  of 
5.7  per  cent,  to  14.1  per  cent.  The  study 
of  these  and  other  figures  has  led  to  the 
following  conclusions: — 

1.  Under  the  \ise  of  antitoxin  the 
death-rate  has  been  reduced,  in  round 
figures  to  about  16  per  cent.,  against  a 
former  death-rate  of  from  65  per  cent,  to 
25  per  cent.  In  favorable  ciicumstances 
the  mortality  is  S  per  cent,  or  lower. 

2.  The  death-rate  varies  greatly  ac- 
cording to  the  promptness  with  which 
the  remedy  is  given.  It  falls  to  3  or  5 
per  cent,  in  cases  injected  upon  the 
first  day,  and  increases  rapidly  until  it 
reaches  35  or  40  per  cent,  in  cases  in 
which  injection  has  not  been  made  be- 
fore the  fourth  day  or  after. 

Results  in  hospital  practice  are  much 
less  satisfactory  than  those  in  private 
practice.  The  reason  for  this  is  prob- 
ably that  in  former  case  the  patients 
are  seen  and  injected  earlier,  probably 
come  from  better  hygienic  surroundings, 
and  show  correspondingly  greater  re- 
sistance. J.  D.  Steele  (St.  Louis  Med. 
and  Surg.  Jour.,  Oct.,  1901). 

Study  of  10,526  cases  of  diphtheria 
showed  that  the  ratio  of  mortality  of 
diphtheria  per  10,000  of  the  living  was 
very  high  in  Boston  previous  to  1895. 
The  ratio  of  mortality  per  10.000  has 
been  very  materially  reduced  since  the 
introduction  of  antitoxin.  The  percent- 
age of  mortality  in  the  "South  Depart- 
ment" (Boston  City  Hospital)  is  lower 
than  that  of  any  of  the  hospitals  at 
home  or  abroad  taken  for  comparison. 
Since  larger  doses  of  antitoxin  have 
been  given  the  death-rate  has  been 
materially  reduced,  this  reduction  hav- 
ing occurred  in  the  apparently  mori- 
bund cases.  No  injurious  efl'ect  has  fol- 
lowed the  use  of  serum.  To  arrive  at 
the  most  satisfactory  results  in  the 
treatment  of  diphtheria,  antitoxin 
should  be  given  at  the  earliest  possible 
moment  in  tlie  course  of  the  disease. 
J.  H.  McCoUom  (Providence  Med.  Jour., 
July,  1902). 

In  the  wards  of  the  Mtllhauser  Hos- 
pital the  average  mortality  was  above 


DIPIITHEIUA.     PIIOPHVLAXIS. 


543 


50  per  cent.;  for  1S95  it  was  38  per 
cent.,  and  for  1890  it  was  28  per  cent. 
During  these  two  years  the  serum  was 
used  in  small  quantities  and  not  in  all 
cases.  In  1897-08-99  and  1900,  when  the 
serum  was  used  freely,  the  mortality 
ranged  between  1.5  and  20  per  cent.  The 
effect  of  the  injection  of  the  serum 
seemed  to  be  beneficial.  When  the  pa- 
tients had  fever,  it  usually  decreased 
rapidly.  All  the  patients  that  required 
tracheotomy  required  it  upon  admission, 
excepting  two  in  whom  it  was  done  the 
day  after  admission.  In  one  case  of 
albuminuria  the  serum  injection  caused 
it  to  disappear  at  once. 

The  causes  of  death  were  various; 
paralysis  of  the  heart,  pneumonia,  etc. 
One  patient  died  shortly  after  admission 
to  the  hospital,  and  one  of  diphtheria 
of  the  bronchioles.  The  dose  of  serum 
varied  from  GOO  to  1.500  units,  repeated 
at  intervals  as  appeared  necessary.  In 
addition,  the  children  received  gargles 
containing  potassium  chlorate,  and  when 
there  was  much  pain  they  were  allowed 
to  swallow  small  pieces  of  ice.  In  the 
severe  eases  the  throat  was  painted  with 
a  solution  of  ferric  chloride.  The  nour- 
ishment was  of  the  most  concentrated 
character.  In  no  case  was  any  spread 
of  the  diphtheritic  process  observed 
after  the  injection  of  the  serum.  Jaeger 
(Deutsehes  Archiv  f.  klin.  Med.,  Bd. 
Ixxiii,  1903). 

Prophylaxis.  —  In  typical  diphtheria 
^\•e  have  to  deal  ^-ith  an  acute  in- 
fectioiis  disease,  in  ■which  we  now  know 
the  nature  of  the  contagion  and  its  ways 
of  spreading.  The  bacilli  present  in  the 
nose  or  throat  of  the  patients  are  the 
active  agents,  and  anything  which  ruay 
either  directly  or  indirectly  be  contami- 
nated by  the  discharge  from  the  affected 
surfaces  may  be  the  means  of  communi- 
cating the  disease  to  others.  Tlie  first 
step  in  prevention  is,  therefore,  the  is- 
olation of  the  diphtheria  patient.  Sus- 
pected cases  should  be  isolated  as  thor- 
oughly and  promptly  as  those  in  which 
the  diagnosis  is  settled.    It  is  to  be  re- 


membered that  during  epidemics  or  in 
any  case  of  exposure  many  of  the  mild 
eases  of  "sore  throat"  are,  in  reality, 
diphtheria,  and  should  be  treated  as  such 
in  this  respect. 

Moreover,  as  has  previously  been 
noted,  diphtheria  bacilli  may  be  found 
in  the  throats  of  those  who,  although 
perfectly  healthy,  have  been  exposed  to 
infection.  This  is  especially  true  of  chil- 
dren, and  in  families  where  diphtheria 
is  present  the  well  children  should  be 
kept  from  attendance  at  schools  or  like 
gatherings  where  they  may  possibly  con- 
vey the  disease  to  others  more  susceptible 
than  themselves.  In  the  course  of  epi- 
demics it  is  often  necessary  to  close  all 
schools  before  the  ravages  of  the  disease 
can  be  controlled.  The  past  year  has 
been  marked  by  the  establishment  in  our 
large  cities  of  a  system  of  inspection  by 
trained  physicians  of  all  school-children 
who  present  the  first  s}Tnptoms  of  illness: 
a  progressive  step  in  preventive  medi- 
cine that  will  undoubtedly  do  much  to 
protect  these  communities  from  epidem- 
ics of  diphtheria.  Suspected  cases  of 
diphtheria  are  to  be  isolated,  but  should 
not  be  put  into  diphtheria  wards  or  hos- 
pitals until  the  diagnosis  is  assured.  Our 
reliance  must  be  upon  the  bacteriological 
diagnosis,  for  in  case  of  exposure  the 
mildness  of  the  individual  case  is  no 
surety  that  it  is  not  dangerous  to  others. 

These  cases  call  for  especial  care,  both 
in  making  and  in  examining  the  cultures. 
With  proper  methods,  twentj'-four  hours 
sliould  sullice  to  settle  the  question  of 
diagnosis.  In  case  of  doubt  the  isolation 
of  the  patient  should  be  continued  and 
the  bacteriological  examination  repeated. 

In  all  our  large  cities  provision  is  now 
made  for  the  treatment  of  diphtheria  in 
special  public  hospitals.  To  these  hos- 
pitals are  sent  all  cases  that  cannot  be 
properly  cared  for  and  isolated  at  home. 


544 


DIPHTHERIA.    PROPHYLAXIS. 


Xew  York  has  recently  added  to  her 
eqiiipment  a  private  hospital  for  the 
treatment  of  contagious  diseases,  includ- 
ing diphtheria.  Here  patients  who  are 
able  to  pay  for  their  care  are  received  as 
private  patients.  The  institution  is  thor- 
oughly equipped  and  ought  to  materially 
aid  in  the  proper  isolation  of  contagious 
cases  among  the  classes  of  people  whose 
aversion  to  the  public  hospitals  has  often 
led  them  to  disregard  the  instruction  and 
even  the  edicts  of  the  health  oiRcers. 

Proper  isolation  of  diphtheria  cases  de- 
veloping in  hospitals  or  asylums,  espe- 
cially those  for  children,  is  of  very  great 
importance,  since  these  institutions  con- 
tain the  most  susceptible  material  for  the 
action  of  diphtheria  bacilli.  They  should 
be  provided  with  diphtheria  wards,  lo- 
cated, if  possible,  in  separate  buildings. 
The  isolation  of  such  wards  should  be 
complete.  In  no  other  way  can  the  in- 
mates of  such  institutions  be  protected 
from  repeated  outbreaks  of  diphtheria. 

In  private  houses  one  or  more  rooms 
should  be  set  apart  for  the  use  of  a  diph- 
theria patient.  No  one  but  the  patient 
and  the  attendants  should  be  allowed  to 
enter  the  sick-room.  .  All  expectoration, 
bits  of  membrane,  etc.,  should  be  re- 
ceived in  cups  containing  a  solution  of 
carbolic  acid,  1  to  40,  or  bichloride  of 
mercury,  1  to  1000.  Instead  of  hand- 
kerchiefs, bits  of  gauze  or  old  linen 
should  be  used,  and  burned  when  soiled. 
All  bedding  and  clothing  used  during 
the  attack  should  be  toaked  for  several 
hours  in  a  1  to  40  solution  of  carbolic 
acid  and  afterward  boiled.  All  eating 
utensils  should  be  sterilized  by  boiling. 
Nothing  that  has  been  in  the  room 
should  be  taken  from  it  without  subject- 
ing it  to  sterilization  in  some  way. 

The  physician  in  charge  of  a  case  of 
diphtheria  before  entering  the  sick-room 
should  cover  his  clothing  by  a  cotton  or 


rubber  gown  reaching  to  the  feet.  The 
gown  should  be  kept  outside  the  sick- 
room and  should  be  sterilized  at  the  con- 
clusion of  the  case.  The  physician  should 
remember  that,  in  examining  the  throat 
in  cases  of  diphtheria,  he  stands  in  great 
danger  of  infection  by  having  the  patient 
cough  in  his  face.  Many  a  life  has  been 
sacrificed  by  careless  exposure  in  this 
way.  As  a  measure  of  protection,  the 
physician  is  often  advised  to  have  a  pane 
of  ordinary  window-glass  held  before  the 
patient's  face  during  inspection  of  the 
throat.  Few  men  willingly  adopt  a  cum- 
bersome device  which  at  the  same  time 
interferes  with  the  examination;  but,  in 
case  the  patient  does  cough  during  the 
examination,  the  physician  should  pro- 
tect himself  by  thoroughly  washing  the 
face  and  hair  with  soap  and  water,  and 
then  using  a  solution  of  bichloride,  1  to 
1000.  The  hands  should  always  be 
washed  and  disinfected  on  leaving  the 
patient's  room. 

Nurses  caring  for  diphtheria  pa- 
tients should  especially  avoid  contract- 
ing the  disease  by  exposing  themselves 
to  the  discharges  from  the  nose  or  throat 
of  the  patient.  Practically  there  is  no 
danger  from  the  breath  of  the  patient. 
The  nurse  should  keep  her  hands  thor- 
oughly clean  at  all  times  and  should 
have  a  disinfecting  solution  of  carbolic 
or  bichloride  at  hand  so  that  she  may  use 
it  constantly.  A  cleansing  gargle  of  nor- 
mal salt  solution,  Dobell's  solution,  or 
Seller's  solution  should  be  used  several 
times  a  day.  Many  advise  the  adminis- 
tration of  an  immunizing  dose  of  anti- 
toxin (300  to  400  units)  at  the  begin- 
ning. 

If  this  is  not  done  at  that  time,  anti- 
toxin in  protective  dose  should  be  given 
at  the  first  sign  of  a  "sore  throat." 

After  leaving  a  diphtheria  case  the 
nurse  should  thorougbly  disinfect  both 


DIPHTHERIA.     PROPHYLAXIS. 


545 


her  clothyig  and  her  person.  It  is  also 
customary  to  require  the  nurse  to  allow 
a  period  of  at  least  five  days  to  pass  after 
leaving  a  case  of  diphtheria  before  as- 
suming charge  of  any  other  patient. 

Antito.^in   should   be  administered   to 
all  persons  who  came  in  contact  with  a 
patient   developing  diphtheria.     Out   of 
546    children    in    the    families    of    diph- 
theria patients  examined  by  the  author, 
157    had    Klebs-Loffler    bacilli    in    their 
throats.     Besides,  out  of  30  adults  ex- 
amined, parents  and  nurses,  13  had  ba- 
cilli  in   their   throats.     Fourteen   cases 
occurred,  on  the  otlier  hand,  in  which 
contagion  was  due  to  convalescents  who 
had    left    the    hospital    with    bacilli    in 
their  throats.     Antitoxin,  prophylactic- 
ally  given,  caused  no  accidents.     AVhen 
diphtheria  follows  in  spite  of  antitoxin, 
the   dose  may  have  been  too   small   or 
the    injection   given    too    late.      Of   502 
children  injected  prophylactically,  13  de- 
veloped diphtheria,  7  of  them  inside  of 
twenty-four   hours   after   the   injection, 
the   other   6   in   tlie   next   twenty-eight 
days.    The  throats  of  47C  of  these  were 
examined,  bacilli  being  found  in  150.    A 
great    amount    of    statistics    show    the 
efficacy    of    antitoxin.      The    immunity 
lasted  from  two  to  twenty-eight  days. 
When  diphtheria  occurred  in  inoculated 
children,  it  was  mild.     It  is  much  like 
vaccination  in  effect,  only  the  immunity 
to   small-pox   conferred   by   vaccination 
lasts  much  longer.     Netter    (La  Presse 
Mfidicale,  April  23,  1902). 
Length  of  Quarantine. — The  bac- 
teriological  researches   of   recent   years 
have  given  us  some  very  definite  informa- 
tion bearing  on  this  point.     It  has  al- 
ready been  noted  that  the  bacilli  may 
persist  in  the  throat  for  weeks  after  an 
attack,  and  that  such  bacilli  have  been 
proved  fully  virulent.     Park  reports  a 
series  of  careful  observations  \ipon  the 
time  of  the  disappearance  of  the  bacilli 
from  the  throat  in  173fi  cases  of  diph- 
theria.    Briefly,  he  found  that  the  bacilli 
had  disappeared  within  1  week  in  3  per 
cent,  of  the  cases,  in  Vs  of  the  cases  at 


the  end  of  the  second  week,  in  '/,  at  the 
end  of  the  third  week,  in  */^  at  the  end 
of  the  fourth  week,  and  in  the  remainder 
the  bacilli  persisted  for  varying  periods 
up  to  91  days.  This  last  case  was  one  of 
simple  nasal  discharge  containing  diph- 
theria bacilli,  from  which  both  nurse 
and  mother  contracted  diphtheria.  The 
mildness  or  severity  of  the  case  gives  no 
basis  for  determining  the  time  that  the 
bacilli  may  remain  in  the  throat.  The 
only  accurate  method  of  determining  the 
period  of  quarantine  is  that  of  making 
cultures  from  the  throats.  Only  when 
cultures  fail  to  show  the  presence  of  the 
bacilli  in  the  throat  or  nose  can  the  case 
be  regarded  entirely  devoid  of  danger 
to  others.  If  cultures  cannot  be  em- 
ployed, we  may  elect  an  arbitrary  period 
of  three  weeks  from  the  disappearance 
of  membrane  for  the  removal  of  quaran- 
tine restrictions.  After  that  time,  if  the 
bacilli  have  not  actually  disappeared 
from  the  throat,  they  are  but  few  in 
number  and  the  danger  of  communica- 
tion is  slight. 

Disinfection  of  the  infected  rooms 
upon  the  termination  of  the  case  should 
be  thorough.  The  walls  and  ceilings  are 
to  be  scrubbed  with  bichloride,  1  to  1000, 
or  rubbed  down  carefully  with  bread:  a 
simple  method  of  removing  the  clinging 
dirt  and  bacteria  by  mechanical  means. 
The  wood-work,  floor,  and  furniture  are 
to  be  scrubbed  with  bichloride.  The 
wood-work,  walls,  etc.,  are  to  be  re- 
painted or  papered  anew.  Carpets,  up- 
holstery, etc.,  can  be  disinfected  by 
steam.  Clothing,  linen,  etc.,  may  be 
boiled.  Anything  which  cannot  be  disin- 
fected by  some  of  these  means  should  be 
burned.  Books  and  toys  that  children 
have  used  during  their  illness  should  be 
thus  destroyed.  Even  the  most  careful 
disinfection  will  in  some  cases  prove  in- 
effective. 
35 


546 


DIPHTHEKIA.     PROPHYLAXIS. 


Apart  from  these  measures  \rith  re- 
spect to  the  eases  already  developed, 
much  may  be  done  to  prevent  the  spread 
of  diphtheria  by  properly  caring  for  chil- 
dren who  may  be  exposed  to  infection. 
Catarrhal  conditions  of  the  nose  and 
throat  undoubtedly  afford  a  favorable 
soil  for  the  location  and  growth  of  diph- 
theria bacilli.  Enlarged  tonsils  and 
adenoid  growths  in  the  naso-pharjoix  fall 
in  the  same  category.  All  such  condi- 
tions should  be  carefully  treated. 

Healthy  mucous  membranes  are  a  safe- 
guard against  attacks  of  diphtheria. 

Immttnization  by  Injections  of  An- 
titoxin.— By  the  injection  of  small  doses 
of  antitoxin  it  has  been  found  possible 
to  induce  an  artificial  immunity  which 
holds  good  for  a  period  of  at  least  four 
weeks,  as  a  rule.  Epidemics  of  diphtheria 
in  children's  hospitals  or  asylums  have 
been  repeatedly  checked  by  protective 
injections  of  antitoxin  in  all  the  children 
exposed. 

The  value  of  immunizing  injections  in 
hospitals  upon  254  children  of  ages  vary- 
ing from  2  months  to  14  years  obser\'ed, 
these  observations  covering  a  period  of 
twenty-one  months.  The  strength  of 
serums  varied  from  100  to  3000  units, 
and  the  dose  from  1  to  10  cubic  centi- 
metres. In  the  beginning,  when  the  in- 
jections were  made  only  upon  patients 
in  beds  near  to  those  which  had  been 
occupied  by  the  diphtheritic  patients,  4 
cases  of  infection  occurred.  When,  how- 
ever, the  injections  were  made  upon  all 
the  patients  of  the  ward,  and,  later, 
upon  all  patients  subsequently  admitted, 
the  disease  did  not  reappear,  except  in  3 
cases  thirty  to  forty  days  after  injec- 
tion, twice  in  children  readmitted  to  the 
hospital,  and  once  with  a  child  that  had 
been  discharged  well  and  returned  at 
the  end  of  a  month  with  an  attack  of 
the  disease.  Two  children  admitted, 
but  not  injected  on  account  of  the  grav- 
ity of  tlieir  condition  (pleurisy,  articular 
rheumatism),  contracted  diphtheria  and 


1  of  them  died.  On  account  of  the  3 
cases  of  infection  developing  one  month 
after  prophylactic  injection,  the  injec- 
tions were  repeated  monthly  upon  chil- 
dren who  remained  for  any  length  of 
time  in  the  hospital.  After  this  plan 
was  adopted  no  new  case  of  diphtheria 
developed  in  the  ward.  Another  series  ot 
immunizing  injections  was  made  in  the 
measles  ward  upon  99  children.  Of  this 
number  there  were  21  cases  that  died, 
all  of  them  under  1  year  of  age;  but 
in  no  case  was  there  diphtheria  or  croup. 

In  the  Children's  Hospital  of  Boston, 
of  180S  patients  immunized  at  least  once 
every  twenty-eight  days,  the  amount  of 
serum  varying  from  150  to  500  units,  7 
had  diphtheria,  3  from  insufficient  dos- 
ing, 2  within  twenty-four  hours  of  the 
injection,  and  2  in  whom  the  time  of 
infection  came  twenty-three  and  twenty- 
two  days,  respectively,  after  giving  an 
amount  which  had  previously  been  ef- 
fective when  given  every  three  weeks. 
Of  829  who  were  not  given  antitoxin, 
or  in  whom  more  than  twenty-eiglit 
days  elapsed  after  the  injections,  9  had 
diphtheria,  besides  3  immunized  adults. 
Immunity  in  any  given  case,  of  no 
matter  how  thorougli  exposure  to  diph- 
theria, may  be  conferred  for  at  least  ten 
days  by  the  injection  of  a  small  dose 
(100  to  250  units)  of  serum,  provided  it 
is  given  twenty-four  hours  previous  to 
actual  infection.  A  larger  dose  (250 
units  for  a  child  of  two,  up  to  500  units 
for  one  of  eight  or  over)  will  confer 
safety  for  three  weeks  under  similar 
conditions.  Morrill  (Boston  Med.  and 
Surg.  Jour.,  Mar.  3,  '98). 

Prophylactic  use  of  antitoxin  will  fur- 
nish an  efl'eetive  means  of  lessening  the 
number  of  cases.  In  over  a  thousand 
cases  immunized  only  six  contracted  the 
disease,  which  was  in  every  instance  mild 
in  form.  It  is  better  to  use  300  units  in 
children  and  500  units  in  adults  to  im- 
munize against  the  disease.  J.  S.  Bill- 
ings (N.  Y.  Med.  Jour.,  Feb.  17,  1900). 

As  diphtheria  antitoxin  is  practically 
harmless,  all  exposed  persons  should  re- 
ceive an  immunizing  dose  in  proportion 
to  age.  Two  hundred  and  fifty  units 
should  be  given  to  children  under  two 
years  and  500  to  all  others.     The  im- 


DIPHTHERIA.    GENERAL  MEASURES. 


547 


munity  will  last  for  at  least  three 
weeks,  provided  a  reliable  antitoxin  is 
used.  All  exposed  persons  should  be 
removed  from  infected  surroundings, 
either  by  thorough  disinfection  of  their 
own  quarters  or  by  removal  to  other 
places.  If  this  be  impossible,  the  im- 
munizing doses  should  be  repeated  every 
third  week.  H.  D.  Jump  (Phila.  Med. 
Jour.,  Jan.  11,  1902). 

In  the  article  on  the  "Use  of  Anti- 
toxin" by  Biggs  and  Giierard  previously 
quoted,  a  summary  of  thirty-five  reports 
covering  17,516  injections  of  antitoxin 
for  the  purpose  of  immunization  is  given. 
Following  these  injections,  131  cases  of 
diphtheria  developed,  109  mild  cases  and 
1  fatal  case  within  thirty  days  of  the  date 
of  injection;  20  mild  cases  and  1  fatal 
after  thirty  days.  The  writers  state  that 
"the  duration  of  immunity  after  injec- 
tion has  not  been  definitely  determined 
and  undoubtedly  varies.  Some  hold  the 
opinion  that  it  lasts  only  one  or  two 
weeks,  others  that  it  extends  over  thirty 
days  or  more.  Four  weeks  may  probably 
be  considered  as  the  average  duration." 
The  results  certainly  justify  the  further 
trial  of  this  method  of  protection. 

General  Measures. — First  of  all,  the 
sick-room  should  be  well  lighted  and 
ventilated.  Care  in  this  respect  is  es- 
pecially necessary  in  children's  hospitals. 
Crowding  a  number  of  cases  of  diph- 
theria together  in  one  ward  is  undoubt- 
edly harmful.  It  is  much  better  to  have 
a  number  of  small  wards,  accommodat- 
ing three  or  four  patients,  than  one  large 
one  in  which  all  are  assembled  together. 
Cases  in  which  pneumonia  has  developed 
should  not  be  kept  in  the  room  with 
those  still  free  from  it.  Attention  should 
be  given  to  feeding  the  patients,  as  the 
best  means  of  enabling  them  to  bear  the 
attack  of  the  disease  iipon  the  vital  pow- 
ers. Usually,  on  account  of  the  soreness 
of  the  throat,  fluid  foods  can  be  best 


taken,  but  semisolids  can  be  given  in 
some  cases.  Our  chief  reliance  must  be 
upon  milk.  It  should  be  given  at  regu- 
lar intervals,  every  two  hours,  and  in 
such  quantity  as  the  patient  will  take. 
There  is  little  danger  of  overfeeding. 
The  difficulty  is  usually  to  get  the  chil- 
dren to  take  sufficient  nourishment.  In 
addition  to  the  milk,  we  may  give  beef- 
juice,  beef-tea,  or  thin  gruels.  In  chil- 
dren that  have  been  intubated  semi- 
solids can  sometimes  be  taken  better  than 
fluid  nourishment.  Bread  and  milk 
answer  the  purpose  in  such  cases. 

Xursing  children  should  be  fed  with 
milk  drawn  by  a  breast-pump.  In  this 
way  the  children  are  saved  the  exertion 
of  suckling  and  the  mothers  are  pro- 
tected from  the  danger  of  infection. 

In  septic  cases  the  children  often  re- 
fuse food  altogether  or  vomit  it  imme- 
diately it  is  taken.  They  may  then  be 
fed  by  the  stomach-tube.  If  the  tube 
cannot  be  passed  through  the  mouth,  we 
can  usually  succeed  in  passing  it  through 
the  nose.  This  method  may  also  be  em- 
ployed in  intubated  cases  where  the  at- 
tempt to  swallow  food  is  followed  by  vio- 
lent coughing  or  choking. 

Eectal  feeding  with  peptonized  milk 
is  a  last  resort,  and  seems  to  be  of  little 
value  in  children. 

Rest  in  bed  is  an  essential  feature  of 
proper  treatment.  Whatever  handling 
or  interference  is  required  should  be  so 
arranged  as  to  tax  the  patient  as  little 
as  possible.  Zeal  for  thorough  local 
treatment  has  often  led  to  fatal  excite- 
ment and  exertion  on  the  part  of  the 
patient.  Especially  in  cases  of  cardiac 
weakness  should  absolute  quiet  be  en- 
joined, and  all  treatment  that  tends  to 
excite  the  child  or  cause  it  to  struggle 
avoided.  Opium  or  morphine  may  be 
used  to  insure  quiet  under  these  circum- 
stances. 


548 


DIPHTHEEIA.     LOCAL  TREATMENT. 


Steam  inhalations  have  long  been  em- 
ployed for  the  purpose  of  increasing  the 
secretions  of  mucus  from  the  mucous 
membranes,  softening  the  diphtheritic 
deposits,  and  hastening  their  separation. 
The  croup-kettle  has  almost  become  a 
household  utensil.  To  increase  the  effi- 
cacy of  the  steam,  carbolic  acid,  turpen- 
tine, eucalyptol  and  other  aromatic  anti- 
septics have  been  added  to  the  boiling 
water.  These  measures  are  of  doubtful 
value  at  any  time,  and  when  they  are 
employed  under  a  close  canopy  at  the 
sacrifice  of  fresh  air,  as  is  usually  the 
case,  may  be  positively  harmful.  The 
testimony  of  adults  is  that,  at  least,  the 
steam  is  very  comforting. 

Convalescents  should  use  disinfectant 
gargles  for  a  considerable  period.  Good 
results  are  obtained  by  the  constant  em- 
ployment of  a  disinfectant  vapor,  as 
eucalyptus,  turpentine,  carbolic  acid, 
ereasote,  or  tar.  Either  of  these  agents 
is  added  to  water  in  a  convenient  ves- 
sel, and  is  constantly  simmering  by  a 
moderate  heat  underneath.  Mildly  de- 
tergent and  antiseptic  gargles,  such  as 
diluted  carbolic  acid,  boric  acid  and 
water,  thymol,  menthol,  wintergreen,  or 
bichloride  of  mercury  (1  to  10,000) 
should  be  frequently  employed  by  all 
persons  exposed  to  diphtheria,  as  the 
nurse,  physician,  and  the  patient  himself. 
Beverly  Robinson  (N.  Y.  Med.  Jour., 
Aug.  5,  '94). 
Local  Treatment.  —  The  local  treat- 
ment in  diphtheria  is  of  importance. 

The  object  sought  in  such  treatment 
has  changed  considerably  within  recent 
years.  We  no  longer  seek  to  remove  the 
membrane  by  local  applications  or  by  me- 
chanical means,  nor  do  we  expect  to  de- 
stroy the  bacilli  in  the  throat.  Experi- 
ence has  taught  us  that  we  can  get  rid 
neither  of  membrane  nor  of  bacteria  by 
local  treatment,  and  also  that  too  ener- 
getic efforts  to  accomplish  these  ends  do 
harm  instead  of  good.  We  have,  there- 
fore, abandoned  the  mechanical  removal 


of  the  membrane,  the  application  of  de- 
structive powders  or  solutions  to  it,  and 
the  use  of  strong  antiseptics  to  the  af- 
fected parts.  We  endeavor  simply  to 
keep  the  nose,  mouth,  and  throat  clear 
of  the  secretions  which  may  either  ob- 
struct them  or  bj'  their  decomposition 
and  absorption  increase  the  toxfemia. 

To  this  end  we  employ  bland  fluids, 
such  as  normal  salt  solution,  or  a  satu- 
rated boric-acid  solution.  The  method  of 
using  the  solution  must  be  varied  to  suit 
each  particular  case.  The  most  effica- 
cious is  undoubtedly  the  fountain-syr- 
inge. To  employ  this,  we  need  only  the 
douche-bag  fitted  with  a  smooth  glass 
nozzle  adapted  to  the  size  of  the  nares. 
The  child  is  wrapped  in  a  blanket  so  that 
the  arms  and  legs  are  controlled.  It  is 
then  laid  upon  its  side  on  a  table  beneath 
the  douche,  the  nozzle  inserted  on  one 
side  the  nose,  and  the  fluid,  which  should 
be  lukewarm,  allowed  to  flow  freely  for 
a  moment.  As  it  escapes  from  the  mouth 
or  the  other  nostril,  it  usually  carries 
with  it  considerable  quantities  of  mucus, 
or  muco-pus,  and  possibly  bits  of  mem- 
brane. The  injection  is  repeated  till  the 
escaping  fluid  is  clear.  Sprays  are  inef- 
fective, and  should  not  be  used. 

This  treatment  should  be  employed 
every  two  or  three  hours  during  the 
height  of  the  disease,  less  often  as  the 
amount  of  secretion  lessens,  but  it  should 
not  be  given  up  until  the  bacteria  have 
disappeared  from  the  tliroat. 

Instead  of  this  apparatus,  we  may  em- 
ploy a  simple  nasal  syringe.  The  best 
form  in  our  judgment  is  the  "bulb  nasal 
syringe  with  hard-rubber  pipe"  made  by 
Whitehall,  Tatum  &  Co.,  of  New  York. 
It  consists  of  a  simple  rubber  bulb,  re- 
sembling that  of  a  Davidson  syringe, 
fitted  with  a  blunt  hard-rubber  tip 
adapted  to  the  nose.  Being  emptied  by 
compression,  it  is  much  more  easily  ban- 


DIPHTHERIA.     GENERAL  TREATilENT. 


549 


died  than  piston-syringes.  With  one  or 
the  other  of  these  apparatuses,  nose  and 
throat  can  be  washed  in  practically  all 
cases.  The  greatest  care  should  be  taken 
not  to  injure  the  mucous  membrane  in 
this  treatment.  Every  abrasion  affords 
a  new  site  for  the  action  of  the  diph- 
theria bacilli. 

Severe  nasal  hasmorrhage  may  be  a 
centra-indication  to  the  continuance  of 
this  measure.  Cardiac  weakness  may 
also  forbid  it,  if  the  child  struggles 
against  it.  A  well-trained  and  skillful 
nurse  should  be  able  to  carry  out  this 
treatment  with  very  little  tax  upon  the 
strength  of  the  patient.  In  some  cases, 
however  skillfully  it  is  done,  the  chil- 
dren fight  against  it  so  fiercely  as  to 
render  its  continuance  inadvisable. 

In  diphtheria  cases  which  liave  been 
subjected  to  frequent  irrigation  with 
antiseptic  solutions  from  the  beginning 
of  the  disease,  the  bacilli  disappear  far 
more  rapidly  than  in  those  in  which 
such  irrigations  have  not  been  employed. 
Occasionally,  when  culture-tubes  are  in- 
oculated immediately  after  irrigation  of 
the  throat  with  antiseptic  solutions  the 
cultures  do  not  show  any  Loeffler  bacilli, 
although  subsequent  examinations  may 
demonstrate  their  presence.  N.  Y. 
Health  Board  (Annual,  '9o). 

In  one  series  of  eases  irrigation  with 
warm  salt  solutions  every  one  to  three 
hours  was  employed;  in  a  second  series 
same  treatment  plus  spray  every  three 
hours  of  pyrozone,  from  5-  to  25-per-cent. 
solution;  in  a  third  series  irrigation  by 
1  to  3000  or  4000  solution  of  bichloride 
of  mercury.  Warm  salt-water  irrigation 
best  to  remove  membranes,  but  bacilli 
disappear  most  rapidly  under  corrosive 
sublimate,  or,  what  is  equally  good,  a 
solution  of  boric  acid,  a  tablespoonful  to 
a  pint  of  water;  latter  solution  used 
without  salt-water.  Berg  (Med.  Record, 
Jan.  12,  '95). 

Case  of  faucial,  nasal,  and  aural  diph- 
theria in  a  child,  aged  3  years,  in  which 
autoreinfeetion  of  the  fauces  took  place 
from   the   ear,   which   continued   to   run 


after  the  first  attack  of  faucial  diph- 
theria, in  which  the  diphtheria  bacilli 
were  found  after  recovery  from  second 
faucial  attack.  The  ear  lost  all  symp- 
toms of  disease  under  the  instillation  of 
formalin  solution  (1  to  1000).  C.  H. 
Burnett  (Phila.  Polyclinic,  May  21,  '98). 
Sodium  sozoiodolate  successfully  used 
as  an  insufflation  in  a  particularly  severe 
case  of  diphtheria.  The  insufflations 
were  made  half-hourly,  and  usually  con- 
sisted of  equal  parts  of  flowers  of  sul- 
phur and  sodium  sozoiodolate.  During 
the  hoarseness,  a  mi.Kture  containing 
0.02.5  gramme  of  pilocarpine  hydrochlo- 
rate  in  infusion  of  digitalis  (3  to  1000) 
was  administered  in  teaspoonful  doses. 
Neumann  (Aerztl.  Rund.,  viii,  p.  523, 
'9S). 

"Uliere  there  is  much  swelling  of  the 
cervical  IjTQph-nodes,  hot  or  cold  appli- 
cations may  be  used.  Heat  is  preferable 
in  infants;  in  older  children  the  ice-cap 
may  be  used.  Flannel  pads  or  spongio- 
pylin  wrung  out  of  hot  water,  or  poul- 
tices, may  be  used  in  the  former  case. 

General  Treatment.  —  With  the  ad- 
vent of  antitoxin  most  of  the  remedies 
for  diphtheria  have  passed  from  use.  A 
few  still  occupy  a  position  which  war- 
rants some  attention.  In  the  treatment 
of  phar}Tigeal  or  tonsillar  diphtheria  the 
tincture  of  the  chloride  of  iron  has  long 
been  regarded  as  of  great  value.  Jacobi 
commends  its  use,  advising  a  daily  allow- 
ance of  1  drachm  for  a  child  1  year  old, 
2  or  3  drachms  for  children  from  3  to  5 
years  old.  It  is  to  be  given  diluted  with 
water  and  glycerin.  He  admits  that  it 
cannot  be  tolerated  by  some  patients  and 
that  alcohol  is  to  be  preferred  in  septic 
cases.  Under  present  conditions  its  use 
must,  therefore,  be  very  limited. 

In  the  treatment  of  lar}Tigeal  diph- 
theria the  best  results  previous  to  the 
use  of  antitoxin  were  attained  by  the 
administration  of  mercury.  The  drug 
was  given  internally  in  the  form  of  the 
bichloride,  or  the  patient  was  treated  by 


550 


DIPHTHEEIA.     GENERAL  TKEATMENT. 


calomel  fumigations.  The  bichloride 
was  given  in  hourly  doses  to  the  amount 
of  ^/g  to  ^/,  grain  in  twenty-four  hours, 
each  dose  being  preceded  and  followed 
by  copious  draughts  of  water.  This 
treatment  was  continued  for  from  four 
to  eight  days,  and  good  results  were 
claimed  for  it. 

Calomel  fumigation  was  a  more  elab- 
orate process.  A  tent  or  canopy  was 
rigged  over  the  patient's  crib.  Beneath 
this  tent  15  grains  of  calomel  were  vola- 
tilized every  two  hours  for  two  days  and 
nights,  then  every  three  hours  for  the 
third  day,  every  four  hours  for  the  fourth 
day,  and  thereafter  three  times  a  day 
according  to  indications.  The  patients 
sometimes  suffered  from  stomatitis  and 
diarrhoea  and  developed  pronounced 
anasmia;  not  infrequently  the  attend- 
ants were  salivated;  but  this  form  of 
treatment  gave  better  results  in  intu- 
bated cases  than  any  other  employed  be- 
fore the  introduction  of  antitoxin. 

Among  other  remedies  that  have  been 
recommended,  pilocarpine,  guaiacol,  ci- 
tric acid,  sodium  hyposulphite,  and 
myrrh  have  received  the  greatest  atten- 
tion; but  the  fact  must  be  borne  in  mind 
that,  in  the  majority  of  cases  treated,  the 
diagnosis  has  not  been  established  by 
bacteriological  examination. 

Pilocarpine  a  precious  auxiliary;  less 
danrreroug  for  children  than  for  adults. 
Degle  (Wiener  med.  Presse,  Dec.  9,  IG, 
'94). 

Pilocarpine  a  specific  in  diphtheria.  C. 
F.  Howe  (Med.  Brief,  Aug.,  '95). 

In  severe  cases  of  diphtheria  a  begin- 
ning may  be  made  by  injecting  a  quarter 
of  a  syringeful  of  a  2-per-ccnt.  solution 
of  pilocarpine,  and  then,  to  keep  up  the 
action  of  the  drug,  it  may  be  given  by 
the  mouth.  If  there  is  no  improvement 
at  tlie  end  of  twenty-four  hours,  another 
injection  is  given.  M.  S.  Barsky 
(Wratsch,  Nos.  4r,,  48,  '95). 

Guaiacol  used  early  seems  to  destroy 
the  bacilli  and  prevent  the  spread  of  the 


pseudomembrane.  Bacteriological  ex- 
amination of  cultures  taken  from  the 
same  throat  before  and  after  its  applica- 
tion has  shown  in  the  iirst  instance  the 
bacilli,  and  in  the  second  none  have  been 
found.  The  formula  is  guaiacol,  10; 
menthol,  1;  sterilized  olive-oil,  10.  The 
same  application  is  of  service  as  a  proph- 
ylactic against  diphtheria  by  applica- 
tion to  the  throat  of  the  healthy  inmates 
of  the  hoxise  in  which  the  disease  has  ap- 
peared. This  has  been  proved  in  two 
epidemics.  In  folliculous  tonsillitis  it 
is  capable  of  cutting  short  the  disease  if 
early  and  thoroughly  applied,  and  even 
in  parenchymatous  tonsillitis  mitigates 
considerably  the  severity  of  the  affection. 
S.  Solis-Cohen  (Phila.  Polyclinic,  No.  16, 
p.  157,  '96). 

One  hundred  and  fourteen  cases  of 
diphtheria  treated  with  a  10-per-cent. 
solution  of  citric  acid  given  by  the 
mouth.  Eleven  deaths  occurred:  a 
mortality  of  9.6  per  cent.  Fifty-six  of 
the  cases  were  mild,  27  were  of  very 
doubtful  prognosis,  and  31  were  de- 
cidedly grave.  Four  of  the  deaths  were 
due  to  sepsis,  1  patient  died  after  trache- 
otomy, and  1  died  of  paralysis  of  the 
heart  during  convalescence.  Of  the  11 
who  died,  as  many  as  5  were  not  brought 
to  the  hospital  until  the  disease  had 
been  running  for  from  four  to  seven 
days.  According  to  the  patient's  age  a 
teaspoonful  to  a  tablespoonful  of  the 
solution  was  given  every  two  hours. 
In  the  beginning  and  in  severe  cases 
smaller  doses  are  given,  but  more  fre- 
quently, as  often  as  every  half-hour  day 
and  night.  Bloch  (Ugeskritt  for  Lilger; 
Deutsche  nied.-Zeit.,  Aug.  10,  '96). 

A  solution  of  sodium  hyposulphite  as 
a  local  application  in  diphtheria  gives 
good  results,  three  or  four  applications 
generally  being  sufTicicnt  to  clear  away 
the  false  membrane.  The  solution  is 
prepared  for  use  by  mixing  equal  parts 
of  pure  glycerin  and  a  saturated  solu- 
tion of  hyposulphite  of  sodium  in  water, 
and  is  applied  with  a  brush  to  the  exu- 
dation and  inflamed  fauces  once  or  twice 
daily,  or  as  often  as  may  bo  deemed 
necessary.  11.  A.  Wickers  (Ijancct,  June 
C,  '90). 

Tlie  internal  use  of  tincture  of  myrrh 


DIPHTHERIA.    TREATMENT.    ANTITOXIN. 


551 


in  diphtheria  recommended.  E.  Graetzer 
(MUnehener  med.  Woch.,  No.  47,  S.  1164, 
'96). 

Tincture  of  myn-h  in  diphtheria  very 
strongly  recommended.  The  mixture  i3 
composed  of  tincture  of  myrrh,  4  parts; 
glycerin,  8  parts;  and  distilled  water, 
to  200  parts.  This  is  given  very  fre- 
quently,— every  hour  or  even  every  half- 
hour  in  the  day-time  and  every  two 
hours  at  night, — infants  up  to  the  age  of 
2  years  taking  a  large  teaspoonful  (75 
minims),  older  children  double  that 
quantity  and  adults  three  times  as  much. 
This  is  continued  until  the  membrane 
has  nearly  disappeared,  when  the  doses 
are  only  given  every  two  hours.  After 
all  the  membrane  has  gone  the  treat- 
ment is  continued  for  a  couple  of  days, 
the  inteiTal  between  the  doses  being  in- 
creased to  three  hours.  In  the  case  of 
older  children  and  adults  a  gargle  con- 
taining Vj-per-cent.  resorein  may  be  em- 
ployed every  hour  or  oftener  in  the  day- 
time and  where  it  is  desired  the  tonsils 
may  be  painted  every  hour  with  the 
tincture  of  myrrh  undiluted.  ^Vliere 
the  larynx  is  involved  the  myrrh-and- 
glyeerin  mixture  in  an  inhaler  or  spray 
to  be  used  every  half-hour.  By  this 
method  only  one  case  out  of  eighty  has 
been  lost,  and  reports  collected  from  sev- 
eral other  practitioners  show  182  cases 
with  22  deaths.  Stroll  (Lancet,  Jan.  1, 
'98). 
Stimulants. — These  are  required  in 
every  case  of  diphtheria  showing  any 
marked  degree  of  constitutional  depres- 
sion, most  of  all  in  septic  cases.  The 
pulse  and  the  general  condition  of  the 
patient  are  the  guides  in  their  adminis- 
tration. 

The  best  of  all  is,  undoubtedly,  alcohol. 
A  child  of  three  or  four  years  can  take 
at  least  1  ounce  of  whisky  or  brandy  in 
twenty-four  hours.  It  should  be  given 
diluted  with  from  4  to  6  parts  of  water. 
In  the  severe  cases  the  quantity  of  alco- 
hol may  be  increased  to  several  times  the 
amount  named  above.  It  is  best  to  give 
it  apart  from  the  food,  as  the  patient 
may  decline  to  take  the  stimulant,  and 


may  be  led  to  refuse  the  food  because  of 
its  admixture.  Xext  to  alcohol,  strych- 
nine is  of  most  value.  The  '/,oo  part  of 
a  grain  may  be  given  every  two  or  three 
hours  to  an  infant  one  year  old;  twice 
that  amount  to  a  three-year-old.  The 
drug  may  be  pushed  till  the  deep  reflexes 
show  an  exaggeration.  Digitalis  and 
like  cardiac  stimulants  may  be  called  for 
by  the  condition  of  the  heart,  but  most 
reliance  is  to  be  put  in  alcohol  and 
strychnine. 

Antitoxin. — The  antitoxin  treatment 
of  diphtheria  has  been  in  general 
use  the  world  over  for  the  past  three 
years,  and  in  that  time  has  won  for  itself 
the  right  to  be  regarded  as  a  specific. 

[The  history  of  the  introduction  of  the 
diphtheria  antitoxin  may  be  found  in 
Welch's  article  in  the  "Transactions  of 
the  Association  of  American  Physicians" 
for  1895,  page  313,  and  in  brief  in  the 
article  on  "Diphtheria"  in  volume  i  of 
the  Annual  of  the  Universal  Med- 
ical Sciences  for  1896.] 

The  antitoxin  is  derived  from  the 
blood  of  horses  that  have  been  sub- 
jected to  repeated  inoculations  of  in- 
creasing doses  of  the  toxins  produced  by 
the  diphtheria  bacillus.  The  course  of 
treatment  usually  occupies  several 
months.  When  immunity  has  been  thor- 
oughly established  in  a  horse,  the  blood 
is  drawn  from  a  jugular  vein  into  steril- 
ized vessels  and  allowed  to  clot.  The 
clear  serum  is  then  siphoned  off  into 
small  sterilized  bottles,  each  of  which 
contains  sufficient  antitoxin  for  one  dose 
and  is  preserved  by  the  addition  of  cam- 
phor or  carbolic  acid  in  small  quantity. 
The  antitoxin  thus  prepared  is  a  clear, 
limpid  fiuid,  having  the  color  of  blood- 
serum.  If  kept  in  a  cool,  dark  place,  it 
remains  clear  and  is  efficient  for  several 
months.  After  a  year  it  begins  to  lose 
some  of  its  power.  Often  before  this 
time  the  serum  becomes  turbid  and  is 


552 


DIPHTHEKIA.     TREATMENT.     AXTITOXIX. 


unfit  for  use.  The  strength  of  the  serum 
is  expressed  in  terms  of  an  arbitrary 
unit,  dependent  iipon  its  power  to  neu- 
tralize definite  quantities  of  diphtheria 
toxins.  ITpon  each  bottle  of  antitoxin 
is  indicated  the  number  of  antitoxin 
units  which  it  contains. 

Little  is  j-et  known  of  the  nature  or 
method  of  action  of  the  antitoxin.  Ac- 
cording to  one  theory,  its  action  is  purely 
chemical,  neutralizing  the  diphtheria 
toxins  present  in  the  blood;  according 
to  another,  it  acts  by  increasing  the  re- 
sisting power  of  the  cells  of  the  body  to 
the  diphtheria  toxins. 

With  the  object  of  investigating  the 
local  antidotal  effect  of  antitoxin,  doses 
of  this  were  injected  in  certain  cases 
with  crude  toxin.  Three  series  of  experi- 
ments made  on  guinea-pigs:  (1)  with 
toxin  alone,  (2)  with  toxin  and  a  half- 
neutralizing  dose  (as  regards  its  lethal 
activity)  of  antitoxin,  and  (3)  with 
toxin  and  a  fully-neutralizing  dose  (as 
regards  its  lethal  activity)  of  antitoxin. 
Of  the  series  treated  with  toxin  alone, 
the  earliest  section  to  show  undoubted 
oedema  was  the  5  V:-l>our  one.  It  was 
more  marked  in  the  24-hour  one.  The 
fi.xed  connective-tissue  cells  in  all  periods, 
from  1  to  24  hours,  appeared  swelled. 
At  no  period  were  there  discernible  signs 
of  fragmentation  of  the  nucleus  nor  of 
proliferation  of  the  cells.  The  number 
of  wandering  cells  seemed  to  vary  di- 
rectly with  the  length  of  the  period  up 
to  24  hours.  In  1-hour  and  2-hour  sec- 
tions the  majority  showed  almost  a  uni- 
form staining  with  ha;matoxyIin.  Frag- 
mentation of  nucleus  was  seen  most 
markedly  in  24-hour  sections,  though  it 
was  also  seen,  but  to  a  less  degree,  in 
lO'/.-hour  .sections.  In  cells  apparently 
endothelial  in  character  the  chromatin 
net-work  stained  faintly  with  haimatoxy- 
lin,  but  was  distinct.  They  were  present 
in  all  sections,  perhaps  in  greatest  num- 
bers in  the  latest  ones.  In  most  sec- 
tions there  were  signs  of  cloudy  swelling 
of  the  superficial  muscular  fibres.  In 
the  second  series  treated  with  toxin  and 
a  half-neutralizing  dose  of  antitoxin  it 


was  impossible  to  be  sure  of  the  reality 
of  cedema  before  5 '/';  hours  after  injec- 
tion. This  period  was  increased  up  to  24 
hours.  Connective-tissue  fixed  cells  ap- 
peared swelled  in  twenty  minutes'  sec- 
tion, and  this  swelling  was  present  in  all 
sections.  The  changes  in  the  wandering 
cells  seemed  to  be  similar  to  those  in 
Series  1.  The  results  of  the  third  series 
treated  with  toxin  and  fully-neutraliz- 
ing dose  of  antitoxin  were  practically 
the  same  as  in  the  second  series.  The 
points  elucidated  by  this  research  seem 
to  be:  (1)  that  the  cellular  changes  are 
degenerative,  and  that  there  is  no  indi- 
cation of  proliferation  of  affected  cells; 
and  (2)  that  antitoxin,  whatever  may 
be  its  antagonistic  effect  generally,  does 
not  locally  act  as  a  chemical  antidote 
to  the  toxin.  J.  J.  Douglas  (Brit.  Med. 
Jour.,  Sept.  3,  '9S). 

We  have,  as  yet,  no  means  of  determin- 
ing accurately  the  dose  of  antitoxin  suit- 
able to  each  case  of  diphtheria.  It  de- 
pends upon  the  severity  of  the  case,  the 
time  of  injection,  and  to  a  slight  extent 
upon  the  age  of  the  patient.  We  judge 
of  the  severity  of  the  case  by  the  location 
and  extent  of  the  membrane  and  the  de- 
gree of  constitutional  depression.  The 
tendency  is  constantl}^  toward  the  use  of 
larger  doses  of  the  antitoxin.  In  the 
early  days  of  its  use  the  antitoxin  was 
comparatively  weak  and  large  quantities, 
as  much  as  20  cubic  centimetres,  were 
required  for  a  single  dose.  Many  of  the 
unfavorable  results  at  first  reported  were 
doubtless  due  to  the  large  quantities  of 
horse-serum  which  it  was  necessary  to 
inject.  It  was  also  a  difficult  and  painful 
procedure  to  introduce  such  quantities 
of  fluid  hypodermically.  The  antitoxin 
now  used  is  many  times  stronger;  so  that 
even  the  largest  doses  rarely  require  more 
than  5  cubic  centimetres.  This  concen- 
tration of  the  serum  leaves  us  mucli  more 
free  in  increasing  the  power  of  the  first 
injection. 

For  children  under  two  years  of  age, 


DIPHTHERIA.    TREATMENT.     ANTITOXIN. 


553 


severe  cases,  including  all  larjmgeal  cases, 
are  usually  given  1000  units,  mild  cases 
600  to  700  units  for  the  first  dose.  For 
children  over  two  years,  in  severe  cases, 
including  all  laryngeal,  1500  to  2000 
units  are  employed,  in  mild  cases  1000 
units  for  the  first  dose.  Some  physicians 
employ  stronger  doses  than  these;  as 
much  as  3000  units  may  be  given  at  a 
single  injection.  If  no  marked  improve- 
ment follows  the  first  injection,  the  dose 
may  be  repeated  in  from  twelve  to 
twenty-four  hours.  Third  injections 
may  be  given,  but  are  rarely  necessary 
and  are  of  little  benefit,  as  the  antitoxin 
has  but  little  influence  by  that  time. 

In  communities  in  which  diphtheria  is 
prevalent,  60  units  sufficient  to  afford 
protection.  Among  10,000  thus  treated 
only  10  acquired  diphtheria.  To  those 
who  developed  diphtlieria  after  the  GO 
units  and  had  a  mild  attack,  neverthe- 
less 150  units  should  be  given.  When 
infection  is  virulent,  GOO  units:  a  full 
curative  dose.  Several  doses  at  inter- 
vals more  serviceable  than  a  single  large 
dose.  Behring  (Deutsche  med.  Woeh., 
Nov.  15,  '94). 

Quantity  required  in  a  case  varies 
from  1000  to  4000  units  of  Behring's 
standard,  according  to  the  weight  of  pa- 
tient and  severity  of  the  disease.  W.  H. 
Park  (Med.  Fortnightly,  Dec.  2,  '95). 

From  1  '/»  to  2  V:  drachms  are  enough 
for  benign  cases  taken  at  the  onset;  4 
to  6  drachms  in  severe  cases  or  when 
they  have  passed  several  days;  up  to  1 
ounce  or  even  beyond  in  very  severe 
cases.  When  breathing  is  embarrassed 
tracheotomy  may  be  rendered  unneces- 
sary by  an  injection  of  4  to  6  drachms, 
followed  by  another  of  from  2  '/a  to  4 
drachms  if  improvement  is  not  satisfac- 
tory. Better  to  inject  at  onset  a  dose 
of  serum  stronger  than  necessary,  cut- 
ting short  the  malady  rather  than  to 
inject  weak  doses  at  intervals.  In  in- 
fants under  1  year  old  as  many  as  15 
minims  may  be  injected  as  the  child 
numbers  months.  In  adults  not  neces- 
sary, unless  case  extremely  grave,  to 
inject  more  than  4  to  6  drachms  the  first 


time.  Rous  (Med.  Press  and  Circular, 
Mar.  20,  '95). 

That  GOO  units  the  most  beneficial  dose 
proved  by  the  collective  investigation  of 
the  Deutsche  medicinische  Wochenschrift, 
bearing  upon  10,312  cases.  Average  per- 
centage of  G  per  cent,  of  deaths  when  000 
units  used,  average  percentage  of  14.6 
when  1000  units  used.     (Annual,  '9G). 

Obseivation  on  a  series  of  cases  of 
diphtheria  that  occurred  in  hospital,  a 
wide-spread  epidemic  being  imminent.  In 
this  outbreak  none  of  the  children  waa 
removed,  but  all  that  had  been  in  any 
way  exposed,  110  in  number,  were 
promptly  immunized.  The  doses  admin- 
istered ranged  from  250  to  500  units, 
according  to  age  of  child.  Four  or  five 
of  these  children  had  sore  throats  with 
small  patches  on  the  following  day. 
Each  of  these  and  all  that  had  already 
developed  the  disease  received  1000  units 
each.  The  result  was  a  prompt  recovery 
in  every  instance  and  no  new  cases  have 
appeared  in  the  institution  since. 

About  same  time  41  cases  of  diph- 
theria appeared  in  rapid  succession  in 
another  institution.  All  were  more  or 
less  complicated  with  measles  and  scar- 
let fever.  Four  initial  cases  did  not 
receive  the  serum-treatment  and  all  died. 
The  remaining  37  cases  received  anti- 
to.xin  treatment  and  but  2  died.  Deduct- 
ing the  fatal  cases,  without  a  single  ex- 
ception, the  174  antitoxin-treated  cases 
developed  no  sequela;,  either  those  re- 
ceiving curative  or  immunizing  doses. 
J.  H.  Lopez  (Med.  News,  July  30,  '93). 

Children  under  eight  years  of  age  are 
given  an  initial  dose  of  500  immunizing 
units,  to  be  repeated  at  intervals  of  six 
hours  if  the  fever  does  not  fall,  if  the 
strength  of  the  patient  does  not  improve, 
or  if  the  local  manifestations  are  spread- 
ing. To  children  over  eight  years  of  age, 
1000  immunizing  units  are  given  as  an 
initial  dose,  and  repeated  at  intervals  of 
eight  to  twelve  hours  if  necessary.  J.  H. 
Musscr  (Univ.  Med.  Mag.,  Mar..  1900). 

For  fifteen  years  before  the  diphtheria 
antitoxin  was  used  the  average  number 
of  deaths  yearly  was  2373;  for  the  four 
years  since  the  use  of  antitoxin  the 
average  was  1341.  In  mild  cases,  seen 
early,   1000  units  are  recommended;    in 


554 


DIPHTHERIA.    TKEATMENT.    ANTITOXIN. 


mild  cases,  seen  late,  1000  to  2000  units; 
in  severe  cases,  seen  early,  from  2000  to 
4000  units;  and  in  severe  cases,  seen  late, 
an  initial  dose  of  not  less  than  3000  or 
4000  units.  W.  H.  Park  (Phila.  Med. 
Jour.,  Mar.  31,  1900). 

A  clinical  study  of  2093  cases  shows 
that  the  recovery  of  the  patient  depends 
almost  entirely  on  whether  or  not  anti- 
toxin is  administered  early  enough  and 
in  sufficient  quantity.  The  amount  of 
diphtheritic  membrane  alone  is  an  im- 
perfect guide ;  it  is  often  necessary  to 
continue  giving  antitoxin  after  this  has 
disappeared,  for  evidences  of  toxaemia 
sometimes  outlast  the  false  membrane. 
Clinical  experience  teaches  that  the 
effects  of  antitoxin  are  only  salutary, 
and  that  there  is  no  danger  in  giving 
too  much.  It  also  teaches  that  the 
sooner  the  total  amount  of  antitoxin 
required  can  be  given,  the  better.  In 
the  cases  mentioned,  therefore,  4000- 
unit  doses  were  given  and  repeated 
every  four  hours  as  long  as  was  neces- 
sary. In  some  exceptionally  severe  and 
late  cases  4000  units  were  given  every 
two  hours,  and  in  some  cases  8000  units 
every  four  hours.  Some  patients  thus 
received  large  quantities  of  antitoxin, 
and  some  moribund  and  apparently 
hopeless  cases  were  saved  from  death. 
Indeed,  some  of  the  recoveries  that  have 
attended  this  mode  of  treatment  were 
so  wonderful  that  only  those  who  saw 
them  could  appreciate  them.  F.  G.  Bur- 
rows (Amer.  Jour.  Med.  Sci.,  Feb.,  1901). 

The  injections  of  antitoxin  may  be 
made  upon  almost  any  part  of  the  body, 
now  that  the  quantity  of  serum  used  is 
comparatively  small;  the  abdomen, 
thighs,  or  back  may  be  preferred.  An 
hypodermic  syringe  capable  of  holding 
5  cubic  centimetres  is  most  convenient, 
but  the  ordinary  hypodermic  may  be  used 
in  emergency.  Some  slight  pain,  red- 
ness, and  redema  may  be  seen  at  the  site 
of  the  injection,  but  nothing  more,  if 
proper  care  be  taken  in  making  the  in- 
jection. 

Reduction  of  poHt-injcetion  accidents 
by  heating  the  scrum.     In   189.'3-90,  out 


of  1365  patients  treated  with  unheated 
serum,  208,  or  15.2  per  cent.,  suffered 
from  post-injection  accidents.  In  1897, 
however,  of  251  patients  injected  with 
the  warmed  serum,  accidents  were  mani- 
fested in  only  12,  or  in  4.7  per  cent. 
The  method  of  preparing  the  serum  is 
as  follows:  It  is  collected  under  condi- 
tions of  as  perfect  asepsis  as  possible, 
and  without  the  addition  of  any  anti- 
septic, and  is  put  into  small  flasks  of 
the  capacity  of  ten  cubic  centimetres, 
closed  with  a  cork  and  a  capsule  of 
caoutchouc.  These  flasks  are  kept  for 
twenty  minutes  at  a  temperature  of  be- 
tween 138°  F.  and  139°  F.  The  heated 
serum  is  no  way  inferior  to  that  not 
so  treated.  Spronck  (Gaz.  Hebd.  de 
M6d.  et  de  Chir.,  Apr.  21,  '98). 

General  eruptions  may  be  seen  in  a 
large  percentage  of  the  cases  in  which 
antitoxin  is  used,  if  watch  be  kept  for 
them.  The  eruption  is  in  the  form  of 
an  urticaria,  as  a  rule,  and  develops  about 
the  tenth  day  after  the  injection.  It  may 
be  transient  and  give  no  trouble  or  may 
continue  for  several  days  and  be  very 
annoying. 

Temporary  albuminuria  has  been  re- 
peatedly noted  after  immunizing  doses 
of  antitoxin,  but  this  disturbance  of  the 
kidneys  has  always  passed  off  without 
symptoms  or  sequelas. 

Swelling  of  the  joints  has  also  been 
reported  in  some  cases,  but  must  be  very 
rare.  These  sequelfo  of  the  use  of  anti- 
toxin seem  to  be  dependent  upon  the 
quantity  of  serum  employed  in  the  injec- 
tion, and  have  certainly  been  much  less 
frequent  since  the  concentration  of  the 
antitoxin  has  allowed  the  use  of  smaller 
quantities  of  the  serum. 

The  effects  of  the  antitoxin  upon  the 
diphtheritic  process  may  be  almost  im- 
mediate, and  should  be  evident  within 
twenty-four  hours  in  all  cases.  Although 
it  has  no  bactericidal  power  whatever,  it 
affects  both  the  local  and  the  general 
condition.    In  the  throat  an  advancing 


DIPHTHERIA.    TREATMENT.     ANTITOXIN. 


555 


process  stops  or  at  once  begins  its  retro- 
gression. The  amount  of  discharge  les- 
sens, the  swelling  diminishes,  the  mem- 
brane ceases  to  spread,  begins  to  soften, 
and  becomes  looser.  The  favorable  in- 
fluence is  quite  as  marked  in  the  larjiix 
as  upon  other  parts.  The  stenosis  is  re- 
lieved, as  a  rule,  and  the  membrane  is 
more  rapidly  thrown  off.  The  general 
testimony  is  that,  of  the  laryngeal  cases, 
a  much  smaller  proportion  requires 
operative  treatment  for  the  relief  of  the 
stenosis  since  antitoxin  has  been  used. 

If  intubation  is  resorted  to,  the  tube 
is  more  often  coughed  out,  or  can  be 
removed  earlier  than  under  any  other 
form  of  treatment. 

In  1892  the  mortality  of  5540  cases  of 
intubation  was  G9.5  per  cent.;  30.5  per 
cent,  recoveries.  In  the  cases  treated 
with  antitoxin  and  operated  upon,  the 
mortality  was  27.24  per  cent.  The  mor- 
tality of  laryngeal  diphtheria  at  present 
rests  at  21.12  per  cent.;  60  per  cent, 
approximately  have  not  required  intu- 
bation; and  the  mortality  of  operated 
cases  is  at  present  27.24  per  cent.  Mc- 
Naughton  and  JIaddren  (Med.  News, 
May  15,  '07). 

In  Boston  the  mortality  in  the  intuba- 
tion-cases has  fallen  since  1895  from  83 
per  cent,  to  as  low  as  23  per  cent,  in 
those  cases  intubated  this  year.  There 
have  been  15  cases  of  diphtheria  of  the 
eye.  In  only  one  case  there  was  de- 
struction of  the  eye,  and  this  organ  was 
not  in  nomial  condition  at  the  beginning 
of  the  attack;  it  is  believed  that  there 
would  have  been  a  number  of  cases  of 
blindness  had  it  not  been  for  the  anti- 
to.xin.  Large  doses  should  be  given 
early  in  the  disease.  J.  H.  McCollum 
(Boston  Med.  and  Surg.  Jour.,  Aug.,  '98). 

In  the  epidemic  of  diphtheria  at  Col- 
chester during  1901  one  of  the  most 
marked  features  was  the  fall  in  case- 
mortality  at  the  isolation  hospital  after 
the  routine  use  of  antitoxin.  Previous 
to  July  IGth  antitoxin  seems  to  have 
been  employed  only  in  the  bad  cases,  and 


the  mean  case-mortality  during  this 
period  was  25.9  per  cent.,  while  during 
the  same  time  the  mean  case-mortality 
among  patients  treated  at  home  was 
only  10.8  per  cent.  From  July  10th 
onward  antitoxin  was  administered  as  a 
routine  measure.  There  was  immedi- 
ately a  remarkable  diminution  in  the 
ease-mortality,  and  for  all  the  cases  up 
to  the  end  of  December  the  mean  case- 
mortality  became  5.8  per  cent.  It  is 
notable  that  the  case-mortality  among 
the  cases  treated  at  home  during  the 
same  period  not  only  did  not  diminish, 
but  was  rather  higher  than  before, — 
viz.:  a  mean  of  14.5  per  cent.  The 
diminution  in  the  number  of  deaths, 
therefore,  at  the  isolation  hospital  was 
not  due  to  a  diminution  in  the  severity 
of  the  disease,  but  must  be  ascribed  to 
the  use  of  antitoxin;  it  was,  moreover, 
abrupt,  and  coincided  exactly  with  the 
administration  of  antitoxin. 

Bacteriological  examination  of  the 
throats  of  the  school-children  proved  of 
considerable  value  in  controlling  the  epi- 
demic. All  children  coming  from  houses 
in  which  a  ease  of  diphtheria  had  oc- 
curred were  examined,  and  were  not 
admitted  to  the  various  schools  until 
notified  as  being  free  from  diphtheria 
bacilli.  As  regards  the  Hofmann  bacil- 
lus, the  opinion  is  expressed  that  it  has 
no  relation  with  the  true  diphtheria 
bacillus.  Diphtheria  bacilli  were  found 
to  persist  for  a  long  period  in  the 
throat;  in  healthy  children  who  had 
not  been  attacked  up  to  ninety-four 
days;  among  those  who  had  suffered 
from  an  attack  up  to  eighty-seven  days. 
Graham-Smith  (Jour,  of  Hygiene;  Treat- 
ment, May,  1902). 

The  constitutional  effect  of  the  injec- 
tion is  as  marked  as  the  local.  Usually 
the  temperature  falls  within  twenty-four 
hours,  the  pulse  improves,  the  mind  is 
clearer,  and  the  patient  is  evidently  bet- 
ter in  every  way. 

Rich  temperature  with  con-csponding 
rapidity  of  pulse,  varying  according  to 
age  and  form  of  disease,  fell  following 
day  and  was  normal  third  day  when  no 


556 


DIPHTHERIA.    TREATMKNT.    ANTITOXIN. 


complications  present.  Distinct  dispar- 
ity between  temperature  and  pulse  fre- 
quently present.  Disturbances  of  the 
circulatory  system,  among  154  cases, 
caused  no  deaths  and  did  not  in  any 
noticeable  way  hinder  recovery.  Variot 
(La  Semaine  M§d.,  Mar.  6,  '95). 

Rise  of  temperature  always  an  im- 
portant one;  return  to  normal  then  very 
gradual,  but  temperature  often  remains 
very  high;  repetition  of  injection  caused 
renewal  of  the  effect  produced.  Kurt 
Miiller  (Berliner  klin.  Woch.,  No.  37, 
'95). 

Prompt  fall  of  temperature  accom- 
panied by  remarkably  improved  sub- 
jective sensations,  typically  altered 
course  of  fever.  Heubner  (Weber  die 
Erfolge  der  Heilserum-behandlung  bei 
Diphtheric,  '95). 

Temperature  of  106.6°  F.  twenty  hours 
after  injection  in  a  child  and  later  on  the 
disparity  noted  by  Variot  between  tem- 
perature and  pulse.  Legendre  (Annual, 
'96). 

Rise    in    temperature    after    injection 
not    only    with    antidiphtheritic    serum, 
but  also  with  artificial  serum  of  Hayem 
and  with  the  serum   of  non-immunized 
animals.     Hutinel,  Debove,  and  Sevestre 
(Annual,  '96). 
The  cases  apparently  severe  or  fatal 
are  transformed  into  mild  ones.     Bag- 
insky  tells  us  that,  in  recording  the  ef- 
fects of  antito.xin  upon  the  various  types 
of  diphtheria,  he  found  it  necessary  to 
require  his  assistants  to  write  their  judg- 
ment of  the  severity  of  the  cases  upon 
the  admission  card,  when  each  case  was 
first  seen,  since  the  antitoxin  in  most 
cases  completely  changed  the  picture. 

The  time  of  the  injection  has  a  most 
vital  relation  both  to  the  immediate  ef- 
fect and  to  the  ultimate  outcome  of  the 
case.  In  experimental  work  an  animal 
can  usually  be  saved  from  a  fatal  dose 
of  diphtheria  toxin,  if  antitoxin  is  given 
within  forty-eight  hours,  but  not  later. 
Clinically  good  results  can  usually  be  had 
if  antitoxin  is  given  within  three  days 
of  the  onset  of  the  diphtheria,  hut  later 


than  that  its  influence  is  greatly  lessened. 
In  the  "Antitoxin  Eeport  of  the  Ameri- 
can Pediatric  Society"  the  mortality  of 
first-day  injections  was  4.7  per  cent.;  of 
second  day,  7.4  per  cent.;  of  third  day, 
8.8  per  cent.;  of  fourth  day,  20.7  per 
cent.,  and  of  fifth  day,  35.3  per  cent. 

Report  of  the  American  Pediatric  So- 
ciety's collective  investigation  into  the 
use  of  antitoxin  in  the  treatment  of 
diphtheria  in  private  practice. 

Result  as  influenced  by  the  time  of  in- 
jection: 5794  cases  with  713  deaths, — 
a  mortality  of  12.3  per  cent.,  including 
every  case  returned;  excluding  218 
cases  moribund  at  the  time  of  injection, 
or  dying  within  twenty-four  hours  of 
the  first  injection,  the  mortality  was  only 
8.8  per  cent. 

Of  the  4120  cases  injected  during  the 
first  three  days  there  were  303  deaths, — 
a  mortality  of  7.3  per  cent.,  including 
every  case  returned.  If,  again,  the  mori- 
bund cases  are  excluded,  there  were 
4013  cases  with  a  mortality  of  4.8  per 
cent.  After  three  days  the  mortality 
rises  rapidly,  and  does  not  materially 
differ  from  ordinary  diphtheria  statis- 
tics. 

Results  as  modified  by  age  of  the  pa- 
tients: The  highest  mortality  is  found 
to  be  under  two  years;  but  including  all 
cases  returned,  even  those  moribund 
when  injected,  the  death-rate  was  but 
23.3  per  cent.  After  the  second  year 
there  is  a  steady  decline  in  mortality  up 
to  adult  life.  Of  359  cases  over  15  years 
old,  there  were  but  15  deaths. 

Paralysis:  Out  of  3384  cases  paralytic 
sequelce  appeared  in  328  cases  (9.7  per 
cent.).  Of  the  2034  cases  which  recov- 
ered, paralysis  was  present  in  276,  or 
9.4  per  cent.  Of  the  450  cases  which 
died,  paralysis  was  noted  in  52,  or  11.4 
per  cent. 

Sepsis:  This  is  stated  to  have  been 
present  in  362  out  of  3384  cases,  or  10.7 
per  cent.  It  was  present  in  145,  or  33 
per  cent.,  of  the  fatal  casCH. 

Nephritis:  Nephritis  was  present  350 
times,  or  in  10  per  cent,  of  the  cases. 
The  statements  on  this  point  are  not 
quite  satisfactory. 


DIPHTHERIA.    TREATMENT.    ANTITOXIN. 


557 


Whole  number  of  cases  of  laryngeal 
diphtheria,  1704;  mortality,  21.12  per 
cent.  (SCO  deaths). 

The  cases  occurred  in  the  practice  of 
422  physicians  in  the  United  States  and 
Canada. 

Operations  employed: — 

(a)  Intubation  in  637  cases;  mortal- 
ity, 20.05  per  cent.  (IGO  deaths). 

(6)  Tracheotomy  in  20  cases;  mortal- 
ity, 45  per  cent.  (9  deaths). 

(c)  Intubation  and  tracheotomy  in 
11  cases;  mortality,  03.03  per  cent.  (7 
deaths). 

Number  of  States  represented,  twenty- 
one,  the  District  of  Columbia,  and  Can- 
ada. 

Non-operated  cases,  1030, — 00.79  per 
cent,  of  all  cases;  mortality,  17.18  per 
cent.  (178  deaths).  (Archives  of  Pediat- 
rics, July,  '96.) 

In  Japan,  prior  to  serum-therapy,  the 
mortality  was  50  per  cent.;  after  its  use 
in  353  cases  the  mortality  was  8.78  per 
cent.  Of  110  cases  in  which  injections 
made  within  forty-eight  hours  after  in- 
vasion, all  ended  in  recovery.  Of  33 
eases  treated  after  eighth  day  of  the 
disease  11  were  lost.  Kitasato  ("Serum 
Treat,  of  Diph.,"  '96). 

In  GOO  cases  of  diphtheria  treated, 
one-half  were  given  antitoxin,  the  other 
half  had  no  antitoxin.  The  Klebs-Loef- 
fler  bacillus  was  found  in  all  cases.  The 
cases  were  treated  in  the  same  hospital, 
had  exactly  the  same  food,  drugs,  and 
stimulants. 

In  the  300  cases  treated  with  antitoxin 
there  were  129  tracheotomies;  60  died, 
the  death-rate  being  20  per  cent. 

In  the  300  cases  treated  without  anti- 
to.xin  there  were  199  tracheotomies  and 
158  deaths, — a  death-rate  of  52.7  per 
cent.  The  earlier  the  ferum  is  used,  the 
better  the  results;  however,  it  is  of 
value  even  when  given  laic.  In  20  per 
cent,  of  laryngeal  cases,  even  when  there 
is  dyspnoea,  it  lessens  the  necessity  for 
operation.  Clubbe  (Brit.  Med.  Jour.,  vol. 
xi,  p.  1177,  '97). 

Statistics  from  the  Imperial  Board  of 
Health  in  Berlin:  The  reports,  gathered 
from  April,  1895,  to  JIarch,  1896,  were 
furnished   by   258   physicians   from   204 


institutions.  Of  9851  cases  of  diphtheria 
treated  with  antitoxin,  1489  proved  fatal, 
or  15 '/,  per  cent.  After  deducting  the 
absolutely  hopeless  cases,  which  perished 
within  the  first  twelve  hours  after  they 
were  seen,  the  mortality  is  reduced  to 
14  Vio  per  cent.  Adding  to  these  9851 
cases  the  result  of  a  former  report  (Jan- 
uary to  April,  1S85)  and  1328  cases  from 
March  to  July,  1890,  published  later,  a 
total  of  13,137  cases,  divided  over  eight- 
een months,  furnished  a  mortality  of 
20S2,  or  15  •/,„  per  cent.  Of  these,  4085 
patients,  or  42.6  per  cent.,  presented  the 
laryngeal  variety,  2744  of  which  were 
operated  upon,  with  a  mortality  of  32  Vio 
per  cent.  The  mortality  of  cases  treated 
on  the  first  day  was  0.6  per  cent.;  that 
of  those  treated  on  the  second  day,  8.3 
per  cent.;  of  those  treated  on  the  third 
day,  12.9  per  cent.;  of  those  treated  on 
the  fourth  day,  17  per  cent.;  and  of 
those  treated  on  the  fifth  day,  23.2  per 
cent.  Dieudonne  (Internat.  Med.  Mag., 
Dec,  '97). 

During  the  year  1896  there  were  ex- 
amined at  the  laboratories  7832  cases 
that  had  been  certified  "diphtheria."  Of 
these  cases,  50G8  had  diphtheria  bacilli 
in  the  throat  and  1302  suffered  from  pa- 
ralysis of  a  more  or  less  marked  kind. 
Of  these  cases,  1096  had  been  treated 
with  antitoxin,  and  there  were  273 
deaths  among  them;  266  received  no 
antitoxin  (that  is,  they  were  most  of 
them  mild  cases  in  all  probability),  and 
there  were  49  deaths.  In  1704  of  the 
cases  examined  in  which  no  diphtheria 
bacilli  were  found,  there  were  177  cases 
of  paralysis  with  59  deaths;  89  of  these 
cases  were  treated  with  antitoxin — 31 
deaths.  There  were,  moreover,  88  not 
treated  with  antitoxin,  28  of  these  suc- 
cumbing. G.  Sims  Woodhead  (Brit.  Med. 
Jour.,  Sept.  3,  '98). 

There  is  no  longer  any  doubt  as  to  the 
curative  action  of  antitoxin  in  diph- 
theria. Of  1.5,792  cases  injected  during 
1002  with  antitoxin  furnished  free  of 
oliarce  by  the  Dopartnient  of  lloaltli  or 
by  its  inspectors,  1S60  died,  a  case  fatal- 
ity of  11.8  per  cent.  If  the  cases  mori- 
bund when  injected  (722  in  number)  are 
deducted  the  case  mortality  is  further 
reduced  to  7.5  per  cent. 


55S 


DIPHTHERIA.    TEEATMElfT.    ANTITOXIN. 


The  one  fact,  important  if  not  new, 
brought  out  in  this  report  is  tlie  great 
advisability — the  almost  imperative 
necessitT — of  the  earliest  possible  admin- 
istration of  antitoxin.  Of  1702  eases 
injected  on  the  first  day  of  the  disease, 
only  So  patients  died  (including  mori- 
bund cases),  a  case  mortality  of  4.9  pei 
cent.  Comment  is  unnecessary.  J.  S. 
Billings,  Jr.,  (N.  Y.  Med.  Jour,  and 
Phila.  Med.  Jour.,  Dee.  12,  1903). 

Coupling  the  danger  of  delay  with  the 
harmless  nature  of  the  antitoxin,  it  is 
quite  plain  that  antitoxin  should  be 
given  in  every  case  where  the  diagnosis 
of  diphtheria  is  probable.  Only  in  mild 
cases  may  we  wait  for  the  bacteriological 
diagnosis.  Especially  in  all  laryngeal 
cases  shoidd  the  immediate  use  of  anti- 
toxin be  advised. 

Xo  harm  is  done  if  the  case  is  not 
diphtheria,  and,  if  it  is,  a  great  advan- 
tage is  gained. 

We  may  safely  assume  that  the  use  of 
antitoxin  is  harmless,  for  if  all  the  re- 
ported cases  of  sudden  death  or  aggrava- 
tion of  cardiac  or  renal  disease  or  other 
unfavorable  influence  were  accepted  as 
proved,  they  could  not,  for  a  moment, 
be  weighed  against  the  accumulated  evi- 
dence of  the  curative  effect  of  antitoxin 
in  diphtheria. 

Effect  on  the  kidneys  of  small  pre- 
ventive doses  (2  to  3  centimetres)  of 
diphtheria  antitoxin  studied  in  73  cases, 
and  shows  no  deleterious  influence.  No 
traces  of  albumin  were  discovered  in 
the  urine.  Also  report  of  a  case  of 
severe  scarlet  fever  and  nephritis  in 
which  diphtheria  supervened,  and  larger 
doses  of  tlie  antitoxin  (10  centimetres) 
were  administered.  The  diphtheria  was 
arrested  at  once,  and  the  nephritis  also 
seemed  to  be  favorably  affected  and  re- 
trogressed, although  more  slowly.  Ro- 
janski   (Botkine's  Gazette,  No.  30,  '90). 

Since  the  introduction  of  the  antitoxin 
treatment  the  incidence  of  paralysis 
following  diphtheria  has  certainly  in- 
creaned.    The  reason  of  tliis  is  believed 


to  be  that  patients  now  recover,  or,  at 
any  rate,  live  long  enough  to  show  symp- 
toms of  paralysis,  who  without  antitoxin 
would  have  died  at  an  earlier  period. 
Though  the  number  of  cases  of  paralysis, 
relatively  as  well  as  absolutely,  has  in- 
creased, the  number  of  fatal  cases  has 
diminished.  If  the  serum-treatment  were 
commenced  early  enough,  the  number  ot 
cases  of  paralysis  would  be  lower  instead 
of  higher  than  before.  E.  W.  Goodall 
(Brit.  Med.  Jour.,  Sept.  3,  "98). 

Antitoxin  has  been  given  in  large  doses 
in  guinea-pigs  and  rabbits,  but  a  case 
has  never  been  seen  in  which  by  itself 
it  had  produced  any  paralytic  symptoms. 
The  heart  fails  earliest  and  most  fre- 
quently because  it  is  the  organ  which 
really  gets  least  rest.  This  condition  of 
overwork  and  ill  nutrition  is  the  great 
factor  even  in  those  paralyses  that  ap- 
pear later.  The  poison  does  its  work, 
but  it  is  only  when  muscle  and  nerve  are 
called  into  functional  activity  that  the 
damage  is  unmasked  and  the  tissues  give 
way  under  a  strain  which  in  health  they 
would  readily  stand. 

Cases  of  paralysis  are  now  not  so  fre- 
quent as  formerly;  and  those  which  do 
occur  are  less  severe.  The  antitoxin 
should  be  used  before  degenerative 
changes  have  been  set  up,  and  enough 
antitoxin  should  be  given  to  neutralize 
not  only  the  lethal  action  of  the  diph- 
theria toxin,  but  also  its  local  and  pa- 
ralysis-producing action.  Sims  Wood- 
head  (Brit.  Med.  Jour.,  Sept.  3,  '98). 

Influence  of  antitoxin  on  diphtheritic 
paralysis  summarized  as  follows:  Up  to 
the  present  the  percentage  of  paralysis 
has  increased,  on  the  whole.  There  is 
some  evidence  that  large  doses — i.e.,  not 
less  than  4000  units — of  antitoxin  are 
more  effective  than  small  ones,  both  in 
preventing  paralysis  and  diminisliing  the 
mortality  due  to  it.  Tlio  earlier  anti- 
toxin is  given  in  diphtheria,  the  less 
likely  is  paralysis  to  follow.  Should  it 
occur  after  early  injection,  it  will  prob- 
ably be  mild  and  of  comparatively  short 
duration.  The  type  of  paralysis  has  be- 
come less  dangerous  to  life.  Finally, 
diphtheritic  paralysis  has  become  more 
prone  to  attack  the  young.  The  full 
value  of  antitoxin  is  only   obtained   by 


DIPHTHERIA.    TREATMENT.    ANTITOXIN. 


559 


using    it    early    and    in    efficient    doses. 
Woollaeott  (Lancet,  Aug.  20,  '99). 

Conclusions  regarding  action  of  diph- 
theria to.xin  on  the  nervous  system  are: 
the   essential   lesion    is   parenchymatous 
degeneration    of    the    peripheral    nen-es, 
the  slight  changes  in  the  anterior-horn 
cells  are  held  to  be  secondary  or  of  ca- 
chectic origin,  while  the  vascular  altera- 
tions   play    but    a    subordinate    rOle    in 
the  pathogeny  of  post-diphtherial  palsy. 
Bielschowsky    and    Nartowski     (Neurol. 
Centralb.,  July  1,  1900). 
That  evidence  has  been  so  fully  pre- 
sented in  the  articles  by  Welch,  Biggs 
and   Guerard,   and   the   Report   of  the 
American  Pediatric  Society,  already  re- 
ferred to,  and  is  so  complete,  that  no 
attempt  is  made  to  introduce  it  here. 

There  are  certain  definite  limitations 
of  the  efficiency  of  the  diphtheria  anti- 
toxin. It  has  already  been  pointed  out 
that  not  all  the  lesions  of  diphtheria  are 
produced  by  the  action  of  the  diphtheria 
bacillus  or  its  toxins. 

Certain  of  them,  especially  the  bron- 
cho-pneumonia and  nephritis,  are  be- 
lieved to  be  due  to  the  action  of  strepto- 
cocci. 

Diphtheria  associated  with  streptococci 
is  the  gravest  form  met  with;  in  chil- 
dren it  is  the  most  frequent  determining 
factor  of  broncho-pneumonia.  E.  Roux 
(Universal  Med.  Journal,  p.  289,  '94). 

In  the  severe  and  most  highly  infec- 
tious forms  of  diphtheria  accompanied  by 
marked  hypercemia  and  swelling  of  the 
faucial  and  adjacent  surfaces,  strepto- 
cocci occur  not  only  in  the  superficial, 
inflamed  parts,  but  in  the  deeper,  con- 
tiguous tissues,  as  the  submaxillary  and 
perilaryngeal  glands  and  the  adjacent 
connective  tissue.  In  some  cases  these 
adventitious  germs,  by  penetrating 
deeply,  cause  not  only  a  cellulitis  which 
may  end  in  suppuration,  but  set  up  a 
bronchopneumonia.  H.  Barbier  (Gaz. 
Mfd.  de  Paris,  Sept.  30,  '94). 

Organisms  present  in  32  fatal  cases: 
LoefTlcr's  bacillus  only,  37.5  per  cent.; 
with  streptococci,  2.5.0;  with  staphylo- 
cocci, 18.7;  with  streptococci  and  staphy- 


lococci, 18.7.  In  all  cases  staphylococci 
pyogenes  aurei  found.  No  fatal  results 
took  place  when  only  cocci  were  present. 
Shuttleworth  (Lancet,  Sept.  14,  '95). 

By  mixing  cultures  of  the  strepto- 
coccus with  those  of  the  Klebs-Loeffler 
bacillus,  a  considerable  increase  in  the 
virulence  of  the  latter  is  observed.  The 
dose  necessary  to  kill  a  guinea-pig  was 
much  less  than  that  required  for  a  cult- 
ure of  the  diphtheria  germ.  If  the  dose 
was  decreased  to  the  point  of  permitting 
life  for  two  or  three  weeks,  there  was 
observed,  besides  emaciation,  a  diminu- 
tion of  the  secretion  of  urine,  which  be- 
came sanguinoleni.  The  autopsy  showed 
especially-profound  alterations  in  the 
kidneys,  visible  to  the  naked  eye.  The 
glomerules  were  swelled,  and  projected 
above  the  cut  surface.  The  microscope 
showed  the  shedding  of  epithelium  from 
the  urinary  tubules  and  the  presence  in 
their  lumen  of  numerous  altered  red 
globules.  These  lesions  cannot  be  ob- 
tained with  pure  cultures  of  the  strep- 
tococcus, but  only  by  adding  to  the 
diphtheria  cultures  the  toxins  of  strepto- 
cocci obtained  from  cultures  four  weeks 
old.  Bonhoff  (Hygienische  Rundschau, 
No.  3,  S.  97,  '90). 

In  eases  of  mixed  infection  the  symp- 
toms of  ptomaine  poisoning  due  to  the 
Klebs-Loeffler  bacillus  may  be  preceded 
by  those  due  to  staphylococci  and  strep- 
tococci, which  latter  may  even  subsist 
before  the  onset  of  the  graver  symptoms. 
If  the  Klebs-Loeffler  bacillus  is  the  "prin- 
cipal invading  germ,"  then  "antitoxin 
will  bring  the  crisis  of  the  disease  within 
twenty-four  hours.  If  it  is  the  strep- 
tococcus, there  will  be  a  long,  hard 
fight."  Streptococcic  angina  is  marked 
by  pain,  and  is  not  benefited  by  anti- 
toxin.   Jaques  (Lancet,  Jan.  1.5,  '93). 

Upon  these  processes  the  antitoxin 
can  have  no  direct  effect.  By  lessening 
the  depression  produced  by  the  diph- 
theria, antitoxin  may  enable  the  patient 
to  resist  the  further  attack  of  the  strepto- 
cocci or  other  pathogenic  organisms;  it 
cannot  be  expected  to  do  more.  It  has 
also  been  urged  against  the  antitoxin 
that  diphtheritic  paralj'sis  is  quite  as  fre- 


560 


DIPHTHERIA.    TKEATMENT.    AIJTITOXIN. 


quent  after  its  use  as  it  was  without  anti- 
toxin. 

To  this  two  reasonable  replies  have 
been  made:  One,  that  the  nervous  sys- 
tem is  most  susceptible  to  the  action  of 
the  diphtheria  toxins  and  therefore  most 
difficult  to  protect;  so  that,  while  anti- 
toxin can  save  the  life  of  the  patient,  it 
cannot  protect  him  from  the  particular 
effect  of  his  disease.  The  other  is  the  in- 
genious suggestion  that  by  saving  the 
lives  of  many  who,  suffering  from  severe 
diphtheritic  infection,  would,  in  all  prob- 
ability, have  died  under  any  previous 
form  of  treatment,  antitoxin  increases  the 
number  of  those  in  whom  we  should  rea- 
sonably expect  to  see  diphtheritic  paraly- 
sis develop. 

In  order  to  determine  the  relation  be- 
tween forms  of  the  Klebs-Loeffler  bacil- 
lus and  the  severity  of  the  disease, 
twenty-seven  eases  studied.  The  follow- 
ing conclusions  submitted:  1.  The  short 
Klebs-Loeffler  apparently  produces  a 
toxin  of  greater  virulence  than  the  longer 
forms,  although  local  manifestations 
may  not  be  so  extensive.  2.  The  long 
Klebs-Loeffler  bacillus  and  the  strepto- 
cocci when  found  alone  (together)  give 
rise  to  a  mild  type  of  the  disease.  3. 
The  streptococcus  is  found  associated 
with  the  short  bacillus  in  the  most  se- 
vere cases;  possibly  by  causing  a  more 
intense  inflammatory  reaction  it  opens 
avenues  by  which  the  toxins  of  both  are 
more  readily  absorbed.  4.  The  beneficial 
action  of  antitoxin  in  cases  in  which  the 
Klebs-Loeffler  bacillus  is  not  present  may 
be  due  to  tlie  fact  that,  although  the 
local  effect  of  different  microbes  varies, 
there  are  many  features  of  similarity  in 
the  constitutional  symptoms  produced 
by  them.  W.  J.  Class  (Jour.  Amer.  Med. 
Assoc,  Apr.  30,  '98). 

The  streptococcus  and  the  dijihtheria 
bacillus  enhance  each  other's  virulence, 
and  diphtheria  antitoxin  has  no  effect 
after  scpticEDmia  has  developed.  Hence 
the  neccBsity  of  beginning  antitoxin 
treatment  at  the  first  indication  of  diph- 
theria infection,  before  tlie  streptococcus 


has  had  time  to  get  in  its  work  and 
increase  the  virulence  of  the  diphtheria 
bacillus  and  to  be  reciprocally  affected. 
P.  Hilbert  (Deut.  med.  Woeh.,  Apr.  14, 
•9S). 

The  method  of  administration  of  the 
antitoxin  and  its  mode  of  action  are  such 
that  it  in  no  way  interferes  with  the  use 
of  any  other  form  of  treatment  that  may 
be  regarded  beneficial.  Being  given 
hypodermically,  it  does  not  disturb  the 
stomach  or  interfere  with  feeding  or 
medication.  Fish,  of  St.  Louis,  has  re- 
cently reported  experiments  going  to 
prove  that  antitoxin  given  by  mouth  is 
effective.  Similar  experiments  made  by 
Park  gave  negative  results.  It  is  doubt- 
ful whether  any  advantage  would  be 
gained  if  it  were  possible  to  introduce  the 
antitoxin  in  this  way. 

Antidiphtheria  serum  given  by  the 
mouth  has  proved  eminently  satisfactory 
in  nine  cases.  The  effect  was  quite  as 
good  as  if  the  serum  had  been  given 
hypodermically,  and  no  evil  results  fol- 
lowed,— no  gastric  disturbance,  no  skin 
eruption,  and  no  joint  or  renal  affection. 
Before  deciding  as  to  the  dose  required, 
however,  further  experience  is  desirable. 
In  the  first  five  cases  the  dose  given 
was  the  same  as  would  have  been  given 
hypodermically.  De  Minicis  (Gaz.  degli 
Osped.,  July  19,  '90). 

For  curative  purposes  the  administra- 
tion by  the  mouth  should  be  restricted 
to  exceptional  cases;  but  for  prophy- 
lactic purposes  this  method  should  re- 
ceive the  preference.  J.  Zahorsky  (N.  Y. 
Med.  Jour.,  Mar.  19,  '98). 

Laryngeal  stenosis  may  call  for  further 
treatment.  The  general  testimony  is 
that  antitoxin  exerts  a  marked,  in  some 
cases  a  marvelous,  influence  upon  diph- 
theritic stenosis.  It  is  also  agreed  that 
since  the  general  use  of  antitoxin  a 
greater  percentage  of  laryngeal  cases 
have  escaped  operative  interference  than 
were  before,  and  of  those  finally  operated 
upon  a  greater  number  had  recovered. 


DIPHTHERIA.     TREATMENT.     ANTITOXIN. 


5G1 


The  triumph  of  antitoxin  has  been  that 
of  intubation  as  well.  (See  Intubatiox.) 
Tracheotomy  has  practically  passed 
out  of  use  in  diphtheritic  stenosis  of  the 
larynx. 

Many  forms  of  treatment  were  for- 
merly combined  with  the  use  of  antitoxin, 
but,  as  the  power  of  the  antitoxin  has 
been  more  fully  demonstrated,  the  tend- 
ency to  rely  upon  it  has  become 
stronger.  At  the  present  time,  apart 
from  the  general  treatment — diet,  rest, 
etc. — after  giving  antitoxin  we  confine 
our  efforts  to  the  careful  cleansing  of  the 
nose  and  throat  and  the  use  of  stimu- 
lants. 

Advantages  of  intubation  in  diph- 
theria. It  is  rapid  and  requires  no  anaes- 
thetic; there  is  no  operation;  the  res- 
piration takes  place  through  the  nat- 
ural openings.  In  these  days  of  anti- 
toxin, if  there  is  skilled  assistance  to 
rely  on  during  the  absence  of  the  opera- 
tor, it  has  enormous  advantages  over 
tracheotomy,  but  these  quickly  disappear 
when  skilled  assistance  is  absent,  and  it 
must  not  be  forgotten  that  tracheotomy- 
tubes  can  now  be  removed  after  a  much 
shorter  period  than  formerly.  Hughes 
(Scottish  Med.  and  Surg.  Jour.,  June, 
'97). 

There  is  still  some  doubt  as  to  the 
method  of  taking  out  the  tube  after 
intubation.  There  are  disadvantages  at- 
tending the  thread  method,  and  espe- 
cially because  the  fixing  of  the  tubes 
thus  produced  docs  not  allow  of  its  free 
play,  and  Iicnce  causes  erosion  of  the 
parts.  The  extractor,  on  the  other  hand, 
is  hardly  possible  in  private  practice,  as 
a  sudden  stoppage  of  the  tube  by  mem- 
brane may  cause  sufTocation  unless  the 
tube  can  be  withdrawn  without  delay; 
it  also  requires  considerable  skill,  espe- 
cially where  a  small  tube  sinks  deeply 
into  the  larynx.  Where  attempts  at 
extraction  cause  a  small  tube  to  sink 
farther  down,  jiressure  with  the  thumb 
on  the  trachea,  just  below  tlie  cricoid 
cartilage,  where  the  end  of  the  tube  can 
be  felt;  the  cough  thus  produced  forces 
the  tube  out.    This  method  of  expression 


never  fails.  The  pressure  may  be  made 
with  both  thumbs,  the  finger  finding 
support  on  the  neck;  it  should  be  di- 
rected inward  and  directly  upward.  If 
more  powerful  pressure  is  e.xerted,  the 
tube  may  be  forced,  not  only  into  the 
mouth,  but  even  completely  out  of  it. 
No  disadvantages  attend  this  method. 
Trumpp  (MUnch.  nied.  Woch.,  Jan.,  '98). 
Conclusions  based  on  treatment  of  100 
cases  of  laryngeal  diphtheria  with  anti- 
toxin in  conjunction  with  intubation: 
Antitoxin  should  be  administered  early, 
without  waiting  for  a  bacteriological 
diagnosis.  Tonsillar  exudate  attended  by 
a  croupy  cough  or  partial  aphonia  is  an 
indication  for  a  full  dose  of  1500  to  2000 
units  of  antitoxin.  Antitoxin  adminis- 
tered twelve  hours  or  more  prior  to  oper- 
ative interference  will  reduce  the  mor- 
tality of  intubated  cases  at  least  .50  per 
cent.  Early  operation  urged.  Results 
are  summarized  as  follows:  Number  of 
operations,  100;  recoveries,  69;  deaths, 
31 ;  mortality  under  3  years,  49  per  cent. ; 
mortality  over  3  years,  19  per  cent. ;  com- 
plicating measles,  8  eases,  5  deaths. 
Shurly  (Jour.  Amer.  Med.  Assoc.,  May 
19,  1900). 

Intubation  has  become  more  common 
since  the  introduction  of  antitoxin,  for 
ca.ses  are  less  severe  and  tracheotomy 
does  not  so  often  become  necessary. 
Primary  tracheotomy  is  indicated  in 
children  under  1  Vj  years  with  out- 
spoken rickets,  serious  collapse,  wide- 
spread pharyngeal  ulceration,  severe 
dyspnoea  and  oedema  of  the  larynx,  spas- 
modic or  mechanical  obstruction  in  the 
larynx,  large  oedcmatous  swellings  (such 
as  subcutaneous  emphysema  of  the 
neck),  bronchial  stenosis,  or  continued 
dyspncea  after  intubation.  Secondary 
tracheotomy  is  indicated  when  the  tube 
has  been  in  several  days  and  dyspnoea 
continues  after  the  fourth  intubation, 
when  membranes  close  the  tube,  when 
laryngeal  abscess  occurs,  when  the  thy- 
mus or  bronchial  glands  arc  enlarged, 
when  frequently  changing  the  tube  gives 
no  relief,  when  the  child  cannot  swallow 
sufiScicnt  food,  and  when  dyspncea  fol- 
lows intubation  twice,  five  or  six  days 
after  intubation,  in  children  imder  2 
years.     Intubation  should  be  performed 


562 


DIPHTHEKIA. 


DISLOCATIONS. 


early,   all   indications    for   tracheotomy 
must  be  overcome,  everything  must  be 
prepared    for    a    possible    tracheotomy, 
patients  must  be  kept  in  a  veil-steamed 
atmosphere,  the  smallest  tube  should  be 
introduced  but  once,  bromides  should  be 
given  before  extubation,  and  all  should 
be  ready  for  a  new  intubation  when  ex- 
tubation  is  done.     In  children   under  2 
years  the  tube  is  left  in  on  an  average 
of  2  to  4  days;  from  2  to  4  years,  3  to 
6  days;    over  5  years,  3  to  4  days.    In- 
tubation  may   be   done   experimentally, 
preliminary   to   tracheotomy   or   during 
tracheotomy,  and  before  or  after  clos- 
ing the  tracheotomy  wound.    In  private 
practice  intubation  is  only  justified  when 
the  physician  has  had  experience,  anti- 
toxin has  been  given,  and  a  good  nurse 
secured.    It  is  only  indicated,  then,  when 
no  bronchial  stenosis  exists,  the  larynx 
is  not  swollen  or  ulcerated,  and  no  indi- 
cations for  tracheotomy  are  noted.    The 
tube  is  left  in  as  long  as  no  indication 
for  secondary  tracheotomy  appears  and 
the  child  bears  it  well.    Eahn  (Jahrbuch 
f.  Kinderh.,  Feb.,  1902). 
The  results  of  intubation  after  the  ad- 
ministration of  antitoxin  have  been  most 
brilliant.     Whereas  two-thirds  of  such 
cases  died  before  the  use  of  antitoxin, 
with  it  about  two-thirds  recover.     The 
indications  and  technique  of  the  opera- 
tion are  described  in  the  article  on  In- 
tubation. 

Tracheotomy  should  be  resorted  to 
only  when  no  trained  intubator  can 
be  had  or  intubation  has  been  tried 
and  has  failed.  The  Continental  prac- 
tice of  resorting  to  a  secondary  trache- 
otomy if  a  tube  has  been  worn  four 
days  rests  upon  no  rational  basis 
and  should  be  abandoned.  By  using 
hard-rubber  tubes,  the  perfection  of 
which  was  one  of  O'Dwyer's  last  labors, 
we  may  leave  the  tubes  in  the  larynx  for 
months  without  danger  of  harm. 

W.  P.  NORTHHUP, 

David  BovAinn, 

New  York. 


DISLOCATIONS. 

Definition. — A  dislocation  is  a  perma- 
nent, abnormal,  total,  or  partial  displace- 
ment from  each  other  of  the  articular 
portions  of  the  bones  entering  into  the 
formation  of  a  joint. 

A  sprain  is  a  temporary,  partial  dis- 
placement, reduced  immediately  and 
spontaneously. 

In  total,  or  complete,  dislocations  the 
articular  surfaces  are  completely  sepa- 
rated, or  touch  each  other  only  at  their 
edges.  In  ball-and-socket  joints  the 
dislocation  is  said  to  be  complete  when 
the  centre  of  the  globular  head  is  dis- 
placed beyond  the  rim  of  the  concave 
socket. 

Lesser  forms  of  displacement  are 
termed  partial,  or  incomplete,  luxations, 
or  subluxations. 

A  diastasis  is  a  subluxation  in  which 
the  separation  occurs  in  a  plane  perpen- 
dicular to  that  of  the  articular  surfaces, 
without  lateral  gliding  of  one  upon 
the  other.  The  most  frequent  examples 
of  this  condition  are  the  so-called  "sub- 
luxation" of  the  head  of  the  radius  in 
children,  and  the  tibio-fibular  diastasis 
in  Pott's  fracture. 

A  dislocation  is  complicated  by  in- 
juries to  surrounding  tissues  of  sufQcient 
importance  to  affect  materially  the  symp- 
toms, prognosis,  diagnosis,  or  treatment. 
It  is  rendered  compound  if  the  laceration 
of  the  soft  parts  establishes  a  communi- 
cation between  the  cavity  of  the  joint 
and  the  outside  air. 

Symmetrical  dislocations  on  both  sides 
of  the  body  (viz.,  both  shoulders,  both 
hips)  arc  termed  double.  If  they  occur 
in  the  one  bone  (jaw,  vertebne),  they  are 
called  bilateral. 

Varieties. — Dislocations  are  classified, 
accoi'ding  (o  their  etiology,  as  traumatic 
and  spontaneous.  Traumatic  disloca- 
tions are  caused,  not  only  by  external  vie- 


DISLOCATIONS.     NOilEXCLATUKE.     SYMPTOMS. 


563 


lence,  but  also  by  muscular  force.  Such, 
for  example,  as  the  forward  dislocation 
of  the  mandible.  Spontaneous  disloca- 
tions are  due  to  pathological  processes 
in  or  about  the  joint  which  so  weaken  its 
normal  supporting  structure  that  luxa- 
tion occurs  gradually  (or  suddenly)  and 
without  recognizable  trauma.  Occurring 
in  extra-uterine  life  these  dislocations  are 
termed  pathological,  while,  if  their  ori- 
gin is  prenatal,  they  are  congenital. 

Nomenclature.  —  Usually  the  distal 
member  of  a  joint  is  said  to  be  dislo- 
cated,— the  most  notable  exception  is  the 
so-called  dislocation  of  the  outer  end 
of  the  clavicle  (acromio-clavicular  joint); 
and  the  direction  of  the  dislocation  is 
that  taken  by  the  dislocated  bone:  thus 
a  backward  dislocation  of  the  humerus 
means  that  the  head  of  the  humerus  has 
been  dislocated  backward  from  the  gle- 
noid cavity,  and  lies  behind  it  (unless  it 
has  been  shifted  by  a  secondary  or  con- 
flecutive  displacement).  Sometimes,  how- 
ever, we  speak  of  a  dislocation  as  of  the 
joint  itself,  dislocation  of  the  elbow,  of 
the  knee;  here,  again,  the  direction  of 
the  dislocation  being  that  taken  by  the 
distal  segment.  Thus,  instead  of  saying 
a  "backward  dislocation  of  the  humerus," 
we  might  say  "a  backward  dislocation  of 
the  shoulder."  Subvarieties  are  named, 
according  to  the  new  anatomical  posi- 
tion of  the  distal  segment,  as  subcoracoid, 
dislocation  of  the  humerus,  iliac  (or  dor- 
sal) dislocation  of  the  thigh. 

Finally,  it  is  well  to  bear  in  mind  the 
distinction  between  "typical"  and  "atyp- 
ical" dislocations,  typical  dislocations 
being  those  in  which  the  attitude  of  the 
limb  is  characteristic,  and  atypical  those 
in  which,  owing  to  the  laceration  of  some 
opposing  structure,  whose  integrity  is 
usually  preserved,  the  characteristic  po- 
sition is  not  present.  An  "atypical" 
backward  dislocation  of  the  hips  is  the 


so-called  "everted  dorsal,"  in  which,  ow- 
ing to  the  rupture  of  the  outer  branch 
of  the  Y-ligament,  the  thigh  is  everted 
instead  of  assuming  the  usual  attitude  of 
inversion  and  adduction. 

Symptoms. — Deformity  is  always  pres- 
ent. The  displacement  of  the  articular 
surface  changes  the  normal  contour:  a 
change  which  can  be  accurately  verified 
by  ascertaining  by  palpation  the  abnor- 
mal position  of  the  various  bony  promi- 
nences; moreover,  the  new  position  of 
the  head  of  the  bone  makes  a  new  and 
abnormal  centre  for  the  movements  of 
the  joint,  and,  in  connection  with  the 
restricting  influence  of  untorn  lijraments 


Fig.  1. — Diagram  to  show  the  action  of  a 
ligament  in  limiting  the  range  of  motion  in 
a  dislocation.     {Slimson,  "Dislocations.") 


or  bony  prominences,  gives  rise  to  a  more 
or  less  characteristic  attitude  and  restric- 
tion of  motion  in  certain  directions. 

The  comprehension  of  the  causes 
which  produce  this  constrained  attitude 
and  restricted  motion,  while  of  great  as- 
sistance in  diagnosis,  is,  in  many  cases, 
absolutely  essential  to  intelligent  manip- 
ulative treatment,  for  those  same  forces 
that  aid  our  diagnosis  we  must  take  into 
account  in  our  efforts  to  effect  reduction. 
These  forces  are  purely  mechanical.  The 
dislocated  bone  plays  the  part  of  a  lever 
whose  long  arm  extends  from  the  attach- 
ment of  certain  ligaments  to  its  distal 
cxtremitv  and  whose  short  arm  is  that 


564 


DISLOCATIONS.    SYMPTOMS.    DIAGNOSIS. 


part  of  the  bone  between  this  point  of 
attachment  and  the  head  of  the  bone. 

The  figure  shows  how  the  ligaments 
opposite  the  side  toward  which  the  bone 
has  been  displaced  are  piit  on  the  stretch 
by  attempts  to  move  the  lower  part  of  the 
limb  in  the  same  direction,  so  long  as  the 
head  of  the  bone  impinges  upon  the  outer 
edge  of  the  articular  surface  or  some 
similar  obstacle.  Hence  the  abnormal 
attitude  and  restriction  of  motion  in 
some  directions — and  possibly  abnormal 
mobility  in  others,  be  it  noted — and 
hence,  also,  the  inference  that  such  an 


Fig.  2. — Diagram  to  show  the  effect  of  atti- 
tude upon   tlie  measured  length   of  the  arm 

(1)  in  dislocation  of  the  right  shoulder  and 

(2)  when  the  bones  are  in  a  normal  position; 
B,  B',  the  acromion.  (American  Tcxt-buuk  of 
Hurypiy.) 


obstacle  is  not  to  be  overcome  by  brute 
force,  but  rather  by  strategy  and  dex- 
terity. 

Shortening  or  lessening  of  a  limb  is 
another  aspect  of  the  deformity.  As  a 
sign,  however,  it  is  most  unreliable.  Fig. 
2  indicates  the  relative  positions  of  the 
bones  in  a  subcoracoid  dislocation  of  the 
shoulder  as  compared  with  the  normal 
joint.  With  the  arm  abducted,  the  short- 
ening is  marked,  but  in  adduction  there 
is  little  or  no  shortening;  indeed,  there 
may  be  some  lengthening. 

Crepitation  of  a  fibrous  quality  may  be 
elicited  during  manipulation  by  friction 


of  the  bone  over  fibrous  or  cartilaginous 
structures,  and  means  nothing.  True 
bony  crepitus  means,  of  course,  a  fract- 
ure. 

Pain  is  always  present,  and  is  due  to 
two  causes.  There  is  the  primary  pain 
caused  by  the  laceration  of  the  tissues  at 
the  moment  of  the  dislocation.  This 
soon  passes  away.  Any  persistent  pain 
is  due  to  pressure  on  nerves,  and  can  only 
be  relieved  by  the  removal  of  that  press- 
ure. 

Loss  of  Function. — This  is  usually 
complete,  and  due  partly  to  the  pain  and 
partly  to  the  fixation  caused  by  the 
changed  relations  of  the  bones. 

Symptoms  of  Old  Unreduced  Disloca- 
tions.— Deformity  of  contour  and  atti- 
tude, as  well  as  restriction  of  motion,  will 
persist  as  long  as  the  dislocation  remains 
unreduced;  but,  as  the  parts  tend  to 
adapt  themselves  to  their  altered  condi- 
tions, the  disability  becomes  progress- 
ively less,  as  a  general  rule,  until  the 
functions  of  the  limb  can  be  fairly-well 
performed.  But  several  conditions  may 
interfere  with  this  restoration  of  func- 
tion. An  excessive  production  of  callus 
may  limit  the  motions  of  the  joint  or 
even  ankylose  it  in  an  awkward  position; 
the  head  of  the  bone  may  be  progress- 
ively displaced  farther  from  its  normal 
situation,  and  the  disability  thus  become 
greater  instead  of  less;  or  an  intractable 
neuralgia  or  oedema  may  result  from 
pressure  on  adjoining  nerves  or  vessels. 

Diagnosis.  —  The  one  demonstrative 
sign  of  dislocation  is  the  recognized  pres- 
ence of  the  head  of  the  dislocated  bone 
in  an  abnormal  position.  One  may  mak& 
the  same  inference  from  the  negative  evi- 
dence; namely,  the  absence  of  the  head 
of  the  bone  from  its  normal  situation. 
Thus,  in  backward  dislocation  of  the 
ribs  or  the  sternum  the  diagnosis  is  made 
by  the  absence  of  the  heads  of  the  bones- 


DISLOCATIONS.    DIAGNOSIS.    ETIOLOGY. 


565 


from  where  they  should  be,  and  not  by 
their  presence  where  they  should  not  be. 

In  such  localities  as  the  fingers  or  knee 
the  head  of  the  bone  may  be  seen;  else- 
where it  may  be  felt,  as  in  the  jaw  (for- 
ward) or  the  shoulder;  or,  again,  the 
diagnosis  may  only  be  ascertained  by 
finding  an  indefinite  mass  which  par- 
takes of  the  motions  imparted  to  the 
bone.  Measurements  may  help;  but,  as 
above  noted,  are  liable  to  be  fallacious. 

In  typical  dislocations  the  attitude  of 
the  limb  and  the  limitation  of  motion 
are  usually  the  first  hint  the  surgeon  ob- 
tains of  the  nature  of  the  case;  but,  we 
repeat,  the  only  conclusive  evidence  is 
the  discovery  of  the  head  of  the  bone  out 
of  its  normal  place. 

Differential  Diagnosis. — The  dif- 
ferentiation of  a  simple  dislocation  from 
a  fracture  at  or  near  the  articular  surfaces 
is  often  difficult,  sometimes  impossible. 
If  the  fracture  is  through  the  neck  of  the 
bone  (without  impaction)  the  dislocated 
head  will  not  move  with  motions  im- 
parted to  the  shaft  of  the  bone;  but  will, 
on  the  contrary,  give  rise  to  a  bony  crep- 
itus, unless  some  soft  parts  are  inter- 
posed. But  if  the  fracture  consists  sim- 
ply of  the  splintering  of  an  articular 
edge,  or  the  tearing  off  of  a  tuberosity, 
the  fragment  may  be  pushed  or  drawn 
away  and  give  no  evidence,  except  per- 
haps a  weakness  in  the  joint,  a  lack  of 
certain  motions,  or  a  tendency  to  recur- 
rence of  the  dislocation,  for  which  we 
can  only  assign  the  fracture  as  a  probable 
cause. 

The  statement  that  mobility  is  in- 
creased in  fracture  and  decreased  in  dis- 
locations is  misleading  and  inaccurate. 
In  fractures  mobility  is  not  increased, 
but  created  where  before  it  was  not.  In 
dislocations  it  is  decreased  in  some  direc- 
tions, but  it  is  not  infrequently  increased 
in  others;    and,  indeed,  with  sufficient 


laceration  of  all  the  soft  parts  it  may  be 
increased  in  all  directions.  A  disloca- 
tion may  be  readily  differentiated  from 
a  contusion  or  sprain  by  examination 
under  ether. 

Etiology.  —  Pbedisposinq  Causes. — 
Normal  predisposing  causes  exist  to  a 
greater  or  less  degree  in  all  joints;  other- 
wise no  joint  not  diseased  could  be  dis- 
located: a  theory  long  since  rejected. 
These  causes  mainly  exist  in  the  con- 
formation of  the  bony  surfaces  which 
make  up  or  surround  the  joint.  In  some 
positions  there  is  little  resistance  to  a 
dislocating  force  properly  applied.  Thus, 
the  wide-open  jaw  may  be  dislocated  for- 
ward by  a  relatively-small  force,  there 
being  but  the  slightest  resistance  of  bone 
and  ligament  to  overcome.  Or,  again, 
the  normal  angle  at  the  joint,  as  at  the 
elbow,  predisposes  to  dislocation  by  ap- 
plying a  transmitted  force  (from  the 
hand)  in  a  direction  oblique  (upward  and 
inward)  to  the  long  axis  of  the  joint,  and 
thus  tends  to  force  the  articular  surfaces 
over  each  other  in  an  abnormal  direc- 
tion. Moreover,  certain  outljang  promi- 
nences may  aid  dislocation  by  acting  as 
fulcra  to  pry  out  the  head  of  the  bone, 
as  does  the  olecranon  in  hyperextension 
of  the  elbow  and  the  acromion  in  hyper- 
extension of  the  shoulder.  Some  joints 
are  also  more  frequently  exposed  to  ex- 
ternal violence  than  others.  Patholog- 
ical predisposing  causes  are  fracture  or 
disease  of  the  bones,  disease  of  the  liga- 
ments or  atrophy  of  muscles  that  act  as 
ligaments,  and  distension  of  the  joint 
with  fluid. 

Immediate  or  Determining  Causes. 
— External  violence  may  cause  disloca- 
tion directly  by  acting  upon  the  articula- 
tion itself,  as  a  dislocation  of  the  humerus 
by  a  blow  upon  the  shoulder,  or  indi- 
rectly by  force  transmitted  through  the 
shaft  of  the  bone,  as  in  the  same  dislo- 


566 


DISLOCATIONS.    PATHOLOGY.    COMPLICATIONS.    PROGNOSIS. 


cation  caused  by  a  fall  upon  the  out- 
stretched hand,  or  more  complexly  by 
leverage,  as  when  a  fall  upon  the  shoulder 
dislocated  the  inner  end  of  the  clavicle 
upward  by  leverage  exerted  on  the  first 
rib  as  a  fulcrum. 

Muscular  action  may  also  be  exerted 
either  directly  or  iridirectly.  Thus, 
yawning  is  a  common  cause  for  disloca- 
tion of  the  lower  jaw.  In  fact,  certain 
persons  can  voluntarily  dislocate  one  or 
other  of  their  joints.  The  most  common 
example  is  the  backward  sublvixation  of 
the  first  phalanx  of  the  thumb;  but  there 
are  also  a  few  subjects  who  can  throw  out 
their  larger  joints,  as,  for  example,  a  man 
who  is  at  present  traveling  about  exhib- 
iting his  power  of  dislocating  both  hips 
and  both  shoulders. 

Pathology  of  Recent  Dislocations. — 
In  joints  relaxed  by  paralysis  or  effusion 
(and  in  the  jaw)  dislocation  habitually 
takes  place  without  laceration  of  the  cap- 
sule. In  all  other  cases  (excepting  the 
voluntary  dislocations  before  mentioned) 
the  capsule  is  torn.  In  enarthrodial 
joints  the  rent  is  on  the  side  toward 
which  the  round  head  of  the  distal  bone 
is  displaced.  In  other  joints  any  or  all 
of  the  ligaments  may  be  torn.  The  firmer 
bands,  instead  of  giving  way  themselves, 
may  strip  up  the  periosteum  or  tear  away 
the  bony  prominences  to  which  they  are 
attached.  Opposing  muscles  put  upon 
the  stretch  may  act  in  the  same  way. 
The  bones  may  also  be  broken  by  impact 
on  each  other;  thus  fracture  of  the  olec- 
ranon occurs  in  anterior  dislocation  of 
the  elbow,  and  a  mutual  bruising  of  the 
head  of  the  humerus  and  shattering  of 
the  rim  of  the  glenoid  cavity  in  disloca- 
tions of  the  shoulder. 

Complications.  —  Fractures  worthy  of 
the  name  of  complications  may  occur. 
Some,  indeed,  such  as  fracture  of  the 
anatomical  neck  of  the  humerus,  may 


prove  insurmountable  obstacles  to  reduc- 
tion. External  wounds,  especially  if  they 
compound  the  dislocation,  may  prove 
serious  complications.  Adjoining  vessels 
may  be  ruptured  and  give  rise  to  fatal 
hemorrhage  or  to  occlusion  and  gan- 
grene, or  to  traumatic  aneurisms.  The 
rupture  of  nerves,  of  which  the  most 
common  is  circumflex  at  the  shoulder/ 
may  cause  permanent  paralysis  and  an- 
esthesia. The  viscera  are  rarely  injured 
unless  by  some  other  associated  trauma. 

In  old  imreduced  dislocations  the  lac- 
erated connective  tissue  about  the  head 
of  the  bone  becomes  thickened  and  forms 
a  pseudocapsule,  while  the  periosteum  on 
which  the  head  of  the  bone  now  rests  is 
stimulated  and  throws  out  a  ridge  of 
bone  so  as  to  form  a  new  articular  cavity, 
sometimes  lined  with  fibrocartilage.  The 
muscles  and  ligaments  shrink  or  elongate 
to  adapt  themselves  to  their  changed  cir- 
cumstances, and  thus  a  comparatively 
useful  new  joint  may  be  formed.  In  the 
meanwhile  an  opposite  train  of  events 
takes  place  in  the  old  joint-cavity.  It  is 
obliterated  either  by  adhesion  of  the  cap- 
sule or  by  filling  up  with  granulation- 
tissue.  Thus  not  only  is  the  dislocated 
bone  fixed  in  its  new  position,  but  also 
the  old  socket  is  obliterated  and  rendered 
unfit  for  its  reception.  It  is  important 
to  note  that  the  scar  may  include  neigh- 
boring vessels  or  nerves  and  by  pressing 
on  them  give  rise  to  neuralgia  or  oedema 
without  any  direct  pressure  by  the  bone 
itself,  and,  moreover,  the  tearing  of  this 
tissue  in  attempts  at  reduction  may  re- 
sult in  fatal  injuries  to  vessel  or  nerve. 

Prognosis. — deduction  is  usually  fol- 
lowed by  repair  of  the  damage  done,  and 
within  a  few  weeks  Ihe  joint  is  as  useful 
as  ever.  Occasionally,  however,  a  perma- 
nent laxity  of  the  capsule  remains,  which 
allows  the  dislocation  to  recur  on  more 
or  less  slight  provocation,  and  with  each 


DISLOCATIONS.     TREATMKNT. 


567 


recurrence  the  tendency  grows  more 
marked.  Occasionally,  also,  without  any 
unusual  evidence  of  injury  to  the  nerves 
at  the  time  of  occurrence  of  the  accident, 
a  dislocation  may  be  the  starting-point 
of  an  intractable  neuralgia,  or  it  may  pre- 
dispose the  joint  to  rheumatism.  The 
complications  above  mentioned  render 
the  prognosis  more  grave. 

In  old  unreduced  dislocations  the 
prognosis  is  different  for  every  individual 
case.  In  some  the  new  joint  will  become 
fairly  useful,  in  others  not  so;  yet  the 
prospect  of  relief  by  operation  is  none  of 
the  brightest. 

Treatment.  —  A  recent  dislocation 
should  be  immediately  reduced  unless 
great  inflammatory  reaction,  swelling,  or 
shock  render  the  infliction  of  ^ain  or 
the  use  of  anaesthetics  inadvisable. 

Anaesthetics  are  of  use  to  overcome  the 
resistance  of  the  muscles  which,  con- 
tracted by  pain  or  fear  of  pain,  oppose 
the  manipulations  necessary  for  reduc- 
tion, or  in  case  the  patient  cannot  or  will 
not  suffer  the  pain  incident  to  those  ma- 
nipulations. Reduction  may  usually  be 
effected  in  "primary"  anjesthesia.  Ether 
is  safer  than  chloroform  for  this  purpose. 

The  choice  of  the  method  of  reduction 
depends  upon  the  recognition  of  the  ob- 
stacles to  reduction.  Aside  from  mus- 
cular opposition,  the  usual  obstacle  is  the 
resistance  offered  by  untorn  ligaments 
or  portions  of  the  capsule  to  motion  in 
certain  directions.  Other  obstacles  are 
interposition  of  the  ligaments  or  mus- 
cles, and  these  may  be  of  such  a  nature 
as  to  demand  operative  interference. 

The  older  methods  of  reduction  by 
means  of  direct  pressure  on  the  head  of 
the  bone  or  traction  by  hand,  by  pulleys, 
or  by  electric  force  have  been,  in  great 
measure,  superseded  by  the  more  scien- 
tific and  practical  method  of  reduction 
by  manipulation,  in  which,  by  a  succes- 


sion of  gentle  movements,  the  head  of 
the  bone  is  brought  opposite  the  tear  in 
the  capsule,  the  opening  is  enlarged  by 
relaxation  of  its  sides,  and  the  head  of 
the  bone  slipped  into  place  by  leverage 
on  the  untorn  portions  of  the  capsule 
and  ligaments,  aided,  if  need  be,  by  trac- 
tion and  pressure  on  the  bone. 

In  old  dislocations  the  manipulations 
useful  in  recent  cases  are  much  less  likely 
to  succeed,  owing  to  the  firm  adhesions 
binding  the  head  of  the  bone  in  its  new 
situation  and  the  obliteration  of  the  dis- 
used articular  cavity.    Moreover,  strong 

'  traction  may  be  required  to  overcome  the 
contraction  of  the  muscles.    Interference 

!  in  such  cases  is  unavoidably  blind  and 
uncertain,  and  involves  much  more  ex- 
tensive laceration  than  took  place  at  the 
time  of  the  original  injury.  So  many 
accidents  have  followed  attempted  re- 
duction by  manipulation  in  these  cases 
that,  if  cautious  manipulation  fails  to 
effect  reduction,  it  is  better  to  leave  the 
dislocation  unreduced  in  the  majority  of 
cases;  or,  if  the  loss  of  function  is  so 
great  as  to  induce  the  surgeon  to  run  the 
risk,  an  open  arthrotomy  may  be  done 
with  the  hope  of  dividing  the  opposing 
structures,  opening  up  the  old  socket, 
and  replacing  the  dislocated  bone. 

The  accidents  which  follow  ill-advised 

j  attempts  at  reduction  are  usually  fract- 
ure of  the  bone  or  rupture  of  vessek, 
leading  to  haemorrhage,  gangrene,  or 
aneurism.     More  rarely  injury  to  large 

,  nerves  has  occurred,  and  even  complete 

1  avulsion  of  a  limb  has  been  recorded. 

;  After-treatment. — After  reduction  the 
joint  need  usually  be  kept  immobilized 

:  only  a  few  days,  and  excessive  motions 
avoided  for  a  few  weeks.  Some  disloca- 
tions require  special  dressings  {cff.,  clav- 
icle). Gentle  passive  motion  should  usu- 
ally be  begun  within  at  least  three  weeks 
to  prevent  adhesions. 


568 


DISLOCATIOXS.     CONGENITAL.     TREATMENT. 


Habitual  dislocations  have  been  cured 
at  the  inner  end  of  the  clavicle  by  peri- 
articular injections  of  alcohol  (Stimson) 
and  at  the  shoulder  bv  injections  of  tinct- 
ure of  iodine.  But  this  method  of  pro- 
ducing adhesions  offers  so  grave  risks  of 
anl-cylosing  the  joint  that  in  the  more 
important  joints  it  is  advisable,  if  the 
tendency  cannot  be  overcome  by  the  pro- 
longed wearing  of  an  immobilizing  ap- 
paratus, or  one  which  allows  only  slight 
motion,  to  excise,  or  take  a  '"reef"  in,  the 
lax  portion  of  the  capsule. 

Congenital  Dislocations. — Under  this 
head  are  included  all  dislocations  sup- 
posed to  have  existed  at  birth — although 
sometimes  not  diagnosed  for  months  or 
years — and  to  have  been  caused  by  a  mal- 
development  .of  the  joint,  hydrarthrosis, 
paralysis,  etc.  Dislocations  produced 
traumatically  in  utero  or  during  delivery 
are  excluded. 

Congenital  dislocations  of  the  hip 
cover  about  90  per  cent,  of  all  cases. 
They  are  more  usual  in  females  than  in 
males.  One  or  both  joints  may  be  in- 
volved. The  typical  cases  are  caused  by 
a  defective  development  of  the  Y-carti- 
lage  and  acetabulum,  which  permits  the 
influence  of  the  weight  of  the  body,  or 
the  contraction  of  the  muscles,  to  drag 
the  head  of  the  bone  out  of  the  socket 
on  to  the  dorsum  of  the  ilium. 

Pubic  and  obturator  dislocations  are 
very  rare.  As  the  child  begins  to  walk 
the  head  is  pushed  farther  upward  until 
it  is  finally  arrested  and  a  new  joint 
formed.  The  head  of  the  bone  is  small 
and  deformed  and  the  real  acetabulum 
obliterated.  Compensatory  changes  ap- 
pear in  the  pelvis,  which  is  tilted  for- 
ward, and  the  lumbar  spine,  which  is 
curved  forward.  If  one  hip  alone  is  in- 
volved, there  is  an  additional  lateral 
curvature,  and  the  child  limps;  if  both 
are  involved,  there  is  no  limp,  Ijut  tlic 


gait  is  peculiar.  The  tilting  of  the  pel- 
vis can  be  made  to  disappear  by  placing 
the  child  upon  its  back  and  flexing  the 
thighs. 

The  prognosis  as  to  the  utility  of  the 
limb  is  fair.  The  patient  will  probably 
be  able  to  get  about,  and  the  deformity 
will  grow  no  worse. 

Treatment.  —  Inasmuch  as  operative 
treatment  has  a  very  high  mortality  and 
often  enough  gives  but  little  or  no  relief, 
while,  on  the  other  hand,  some  cases — 
double  as  well  as  single — reach  adult  life, 
undiagnosed  and  untreated,  with  com- 
paratively-slight deformity  and  no  dis- 
ability except  a  waddling  gait,  it  is  proper 
— Hoifa  and  Lorenz  to  the  contrary  not- 
withstanding— to  institute  treatment  by 
palliative  measures.  For  unilateral  dis- 
locations an  elevated  sole  to  the  shoe, 
and,  if  necessary,  an  apparatus  to  pre- 
vent the  head  of  the  femur  from  riding 
up  any  higher  on  the  ilium,  fulfill  the 
indications.  Or  in  cases  under  5  or  6 
years  of  age — single  or  double — pro- 
longed traction,  for  even  as  long  as  two 
years,  may  produce  material  and  per- 
manent improvement.  Mikulicz  claims 
to  be  able  to  effect  reduction  by  ma- 
nipulation. An  injection  of  a  10-per- 
cent, solution  of  zinc  chloride  above  the 
head  of  the  bone  has  been  advocated  for 
the  purpose  of  strengthening,  by  new 
bony  formation,  the  upper  rim  of  the 
new  acetabulum. 

Of  the  operations,  that  of  Lorenz  is  a 
type.  He  makes  a  vertical  antero-ex- 
ternal  skin  incision,  divides  the  fascia 
lata  transversely,  separates  the  muscles, 
frees  the  bone  by  a  cross-cut  in  the  an- 
terior surface  of  the  capsule,  gouges  out 
the  old  acetabulum,  making  a  strong  up- 
per rim  to  it,  and  replaces  the  bone  by 
extension,  aided  by  a  traction  apparatus. 
Immoljilization  is  replaced  by  passive 
motion  at  the  end  of  four  weeks,  and  the 


DISLOCATIOXS.     PAXHOLUUICAL.     SPECIAL. 


569 


child  begins  to  walk  with  assistance  two 
weeks  later.  No  further  apparatus  is 
used.  In  difficult  cases  Lorenz  advises 
a  preliminary  course  of  two  weeks'  ex- 
tension by  a  thirty-pound  weight. 

Congenital  shoulder  dislocations  are  to 
be  treated  according  to  similar  principle. 

The  anterior  knee  dislocations  are 
easily  reduced,  and  a  good  functional  re- 
sult may  be  predicted. 

Pathological  Dislocations.  —  Paralytic 
("myopathic")  dislocations  occur  usually 
in  the  shoulder,  where  the  deltoid  and 
scapular  muscles  form  such  important 
accessories  to  the  joint. 

Dislocations  by  effusion,  erosion,  or 
other  articular  processes  occur  in  the 
course  of  the  eruptive,  continued,  or 
rheumatic  fevers.  The  hip  is  commonly 
affected. 

Special  Dislocations. 

Dislocations  of  the  Lower  Jaw. — 
The  dislocations  may  be  single  or  double. 
Upward  or  backward  dislocations  are 
very  rare.  In  the  former  the  condyle  is 
driven  through  the  base  of  the  skull,  in 
the  latter  back  through  the  anterior  wall 
of  the  external  auditory  meatus. 

Forward  Dislocations. — The  lower  jaw 
projects  forward,  the  mouth  cannot  be 
closed,  the  condyles  may  be  seen  and  felt 
in  front  of  the  eminentia  articularis.  The 
glenoid  fossa  is  empty.  In  unilateral  dis- 
locations the  chin  is  deviated  to  the  op- 
posite side.  The  pain  is  usually  not 
great. 

The  usual  cause  of  forward  disloca- 
tions is  a  wide  opening  of  the  mouth  in 
yawning,  laughing,  or  introducing  some 
large  object.  It  is  more  frequent  in 
women  than  in  men.  When  the  mouth 
is  wide  open  the  external  lateral  ligament 
is  relaxed  and  the  external  pterygoid 
muscle  draws  the  condyle,  and  the  inter- 
articular  cartilage  with  it,  well  forward 
on  the  emincnta  articularis.     A  slight 


overaction  of  this  muscle  carries  the  con- 
dyle over  the  summit,  whence  it  plunges 
forward  and  upward  under  the  zygoma, 
and  is  then  held  by  the  balance  of  forces 
between  the  muscles  pulling  upward  and 
forward  and  the  external  lateral  ligament 
pulling  upward  and  backward.  The  in- 
terarticular  cartilage  accompanies  the 
condyle,  at  least  part  of  the  way.  The 
capsule  is  not  torn. 

Reduction  is  accomplished  by  opening' 
the  mouth  more  widely  to  relax  the  liga- 
ment and  then  pressing  the  condyle  back- 
ward and  then  a  little  downward.  A 
fairly-successful  method  is  by  grasping 
the  jaw  on  either  side  with  the  thumbs 
on  the  molar  teeth  and  the  fingers  un- 
der the  jaw  outside.  As  the  jaw  snaps 
back  the  thumbs  must  be  quickly  slipped 
into  the  hollow  of  the  cheeks  to  avoid  be- 
ing bit.  Reduction  of  one  side  at  a  time 
is  sometimes  easier.  Anesthesia  may  be 
required  to  overcome  the  contraction  of 
the  muscles. 

Not  infrequently  this  dislocation  tends 
to  become  habitual.  To  overcome  this 
the  meniscus  may  be  sutured  in  place. 
Injection  of  tincture  of  iodine  has  been 
proposed. 

Dislocations  of  tue  Spine. — Dislo- 
cation of  the  lumbar  and  dorsal  vertebrae 
is  almost  always  complicated  by  and  con- 
founded with  fracture.  Extension  and 
local  pressure  have  occasionally  effected 
reduction;  operative  treatment  should 
be  resorted  to  in  hopeful  cases. 

Dislocations  of  the  occiput  (from 
the  atlas)  and  the  atlas  (from  the  axis) 
have  been  diagnosed  post-mortem.  Lac- 
eration of  the  vertebral  arteries  and  the 
medulla,  with  or  without  fracture  of  the 
odontoid  process,  causes  instant  death  in 
most  cases. 

Dislocation  of  the  Lower  Cer- 
vical Vertebrae. — This  may  be  double 
or  single,  complete  or  incomplete,  for 


570 


DISLOCATIONS.     STERNUM.     RIBS.     CLAVICLE. 


ward  or  back-ward,  or  bilateral  in  oppo- 
site directions.  If  the  dislocation  is  uni- 
lateral (forward),  the  head  is  turned  to 
the  opposite  side,  on  which  side  the  mus- 
cles are  contracted.  On  the  side  of  the 
dislocation  the  dislocated  bone  may  be 
felt,  and  its  spinous  process  is  deflected 
toward  that  side.  In  bilateral  forward 
dislocations  the  head  may  be  bent  far 
forward  and  the  dislocated  bone  (usually 
the  fifth)  felt  in  the  back  of  the  neck,  or 
the  head  may  be  extended  and  the  bone 
palpable  within  the  pharjTix.  The  symp- 
toms depend  upon  the  amount  of  injury 
to  the  cord.  Damage  to  the  cord  above 
the  third  cervical  vertebrffi  causes  death 
by  cutting  off  the  phrenic  nerves.  Be- 
low this  point  the  result  will  be  a  paraly- 
sis more  or  less  durable  according  to  the 
nature  of  the  lesion. 

The  mechanism  of  the  unilateral  for- 
ward and  bilateral  dislocations  in  op- 
posite directions  is  abduction  (lateral 
flexion)  and  rotation,  by  -which  the  in- 
ferior articular  process  of  the  upper  ver- 
tebra is  lifted  over  the  superior  process  of 
the  lower  one.  Bilateral  forward  dislo- 
cations are  caused  by  hyperflexion,  back- 
ward by  hyperextension  and  direct  press- 
ure. 

Treatment. — Reduction  should  be  at- 
tempted at  once.  Unilateral  dislocations 
are  to  be  reduced  in  the  way  they  were 
produced;  i.e.,  by  abduction  and  rota- 
tion, aided  by  direct  manipulation,  so  as 
to  lift  the  disarticulated  bone  back  into 
place. 

Traction  and  local  pressure  have 
proved  effectual  in  the  reduction  of  bi- 
lateral dislocations. 

After  the  reduction  the  patient  should 
be  kept  quiet  for  some  weeks.  A  plastcr- 
of-Paris  splint  for  head  and  neck  is  ad- 
visable. 

These  means  failing,  if  there  seems 
any  hope  of  recovery  by  renewing  the 


pressure  from  the  cord,  the  dislocation 
should  be  cut  down  upon  aseptically  and 
an  attempt  made  to  reduce  it  by  remov- 
ing such  ligamentous  or  bony  obstacles 
as  may  exist. 

Dislocations  of  the  Sternum:.  — 
Dislocations- — forward  or  backward — of 
the  body  from  the  manubrium  are  usu- 
ally accompanied  by  serious  interference 
with  respiration  and  circulation.  From 
fracture  the  diagnosis  is  made  by  finding 
the  second  costal  cartilages  attached  to 
the  manubrium  and  torn  from  their  ar- 
ticulation with  the  body.  Inasmuch  as 
the  injury  is  due  to  great  violence,  direct 
or  indirect,  the  associated  injuries  play  a 
large  part  in  the  prognosis.  Reduction 
is  effected  by  dorsal  flexion  and  direct 
pressure. 

Dislocations  of  the  ensiform  proc- 
ess are  a  tilting  either  forward  or  back- 
ward. The  symptoms  are  pain  and  per- 
sistent vomiting.  Pressure  with  the 
fingers  or  with  a  sharp  hook  introduced 
underneath  the  skin  will  reduce  the  dis- 
location. 

Dislocations  of  the  Ribs  and 
Costal  Cartilages. — The  ribs  may  be 
dislocated  forward  from  the  spine  or  for- 
ward or  backward  from  each  other  or 
from  their  costal  cartilages.  The  car- 
tilages may  be  dislocated  from  the 
sternum. 

The  symptoms  and  treatment  are  the 
same  as  of  fracture  of  the  ribs.  Reduc- 
tion, followed  by  the  application  of  a 
tight  head-band  of  adhesive  plaster  three- 
fourths  of  the  distance  around  the  chest. 

Chondro-stcrnal  dislocations  usually 
recur. 

Dislocations  of  the  Inner  End  of 
THE  Clavicle. — The  clavicle  may  be  dis- 
located forward,  backward,  or  upward,  in 
this  order  of  frequency. 

Forward  dislocation  may  be  complete 
or  incomplete.    The  head  of  the  bone  is 


DISLOCATIONS.    CLAVICLE. 


571 


prominent  and  may  be  displaced  inward. 
The  shoulder  sinks  downward  and  in- 
ward. The  arm  is  useless.  There  is  local 
pain.  This  dislocation  is  usually  caused 
by  a  forcible  depression  and  pushing 
backward  of  the  shoulder,  by  which  the 
centre  of  the  clavicle  comes  to  rest  on 
the  first  rib,  and  on  it  as  a  fulcrum  the 
inner  end  is  pried  upward  and  forward. 
By  pulling  the  shoulder  upward  and 
backward  and  pressing  on  the  dislocated 
bone  reduction  is  affected;  but  reten- 
tion is  often  diiTicult.  Dorsal  decubitus 
with  a  figure-of-8  bandage  aboiat  the  two 
shoulders,  the  turns  crossing  in  the  back, 
may  prove  effective  or  may  be  reinforced 
by  direct  pressure  by  a  molded  plaster-of- 
Paris  splint,  a  hernial  truss,  or  a  pad  re- 
tained in  position  by  adhesive  plaster,  or 
a  figure-of-8  bandage,  crossing  in  front. 
If  all  precautions  fail  and  the  dislocation 
becomes  habitual,  two  or  three  biweekly 
injections  of  alcohol  with  immobiliza- 
tion may  be  attempted,  or  the  capsule 
exposed  and  shortened. 

Backward  dislocations  may  be  either 
complete  or  incomplete.  The  head  of  the 
bone  passes  backward  and  may  compress 
any  of  the  important  structures  at  the 
root  of  the  neck.  This  dislocation  may 
be  caused  by  direct  violence  or  by  forc- 
ing the  shoulder  forward  and  inward. 
Eeduction  is  effected  and  maintained  by 
drawing  the  shoulder  backward  and  out- 
ward and  retaining  it  in  that  position. 

Upward  dislocation  is  caused  by  de- 
pression of  the  shoulder.  The  head  of 
the  bone  rests  on  the  episternal  notch, 
having  passed  behind  the  sternal  head  of 
the  sterno-mastoid.  Reduction  is  made 
by  drawing  the  shoulder  upward  and  out- 
ward and  pressing  the  head  of  the  bone 
down.  Here,  again,  retention  is  diffi- 
cult, and  Malgaigne's  patellar  hooks 
have  been  suggested  as  an  adjunct  to  the 
treatment. 


DiSLOCATIOXS  OF  THE  OUTER  EnD  OP- 

THE  Clavicle. — The  usual  variety  is  up- 
ward or  upward  and  outward.  Rarely  a 
subacromial  dislocation  occurs.  The  so- 
called  subcoracoid  dislocations  are  prob- 
ably mythical. 

Upward  Dislocation.  —  The  acromial 
end  of  the  clavicle  rises  more  or  less 
above  the  acromion,  and  may  be  dis- 
placed outward  over  it.  There  is  fre- 
quently fracture  of  the  articular  edges. 
The  usual  cause  is  a  blow  on  the  shoulder. 


Fig.  3. — Adhesive-plaster  dressing  for  up- 
ward dislocation  of  acromial  end  of  clavicle. 
{American  Textbook  of  Surpery.) 

Reduction  is  easy,  retention  difficult. 
Although  non-reduction  causes  almost 
no  loss  of  function  and  but  little  de- 
formity, Stimson's  retention  dressing  is 
recommended  for  its  simplicity  and  ef- 
ficiency (Fig.  3).  A  long  strip  of  ad- 
hesive plaster  three  inches  in  width  is 
placed  with  its  centre  under  the  point 
of  the  flexed  elbow  and  its  ends  carried 
up  in  front  of  and  behind  the  arm,  cross- 
ing over  the  end  of  the  clavicle,  and  se- 
cured to  the  front  and  back  of  the  chest. 


DISLOCATIONS.    SUBACROMIAL.    SHOULDER. 


respectively,  while  the  bone  is  held  in 
place  by  pressure  upon  the  clavicle  and 
elbow. 

Recurrence  can  be  readily  detected 
through  the  plaster.  For  additional  se- 
curity the  forearm  should  be  supported 
in  a  sling,  and  the  arm  bound  to  the 
chest.  Care  must  be  exercised  not  to 
cause  pressure  sores  over  the  bony  prom- 
inences at  the  elbow. 

SuBACEOiiiAL  Dislocations. — A  few 
cases  are  recorded  in  which  the  outer  end 
of  the  clavicle  was  forced  down  and 
caught  under  the  acromion.  Direct  vio- 
lence and  muscular  action  are  the  re- 


applied obliquely  in  the  bony  surface  and 
directly  on  the  capsule  of  the  joint, 
through  which  the  head  of  the  bone  is 
then  forced. 

Tarieties. — Four  divisions  may  be 
made  according  to  the  direction  in  which 
the  head  of  the  bone  leaves  the  socket, 
and  these  subdivided  according  to  the 
point  at  which  it  comes  to  rest,  or  accord- 
ing to  the  position  of  the  limb,  as  fol- 
lows:— 

rSubcoracoid  (most  common). 

Anterior J  Intracoracoid   (exceptional). 

(Subclavicular. 


Fig.  4. — To  show  the  range  of  positions  that  may  be  taken  by  the  head  of 
the  humerus  after  primary  displacement  forward  or  downward  in  any  of  the 
directions  between  the  arrows.     {Stimson,  "Dislocations.") 


corded  causes.  Reduction  was  easy  by 
drawing  the  shoulder  outward,  and  there 
was  tendency  to  recurrence  in  only  one 
case. 

Dislocations  of  the  Shoulder. — 
These  dislocations  are  as  numerous  as  all 
other  dislocations  taken  together.  They 
are  rare  in  youth  and  old  age,  and  more 
frequent  in  men  than  in  women.  This 
frequency  is  explicable  by  the  exposure 
of  the  joint  to  trauma  and  its  conforma- 
tion. The  glenoid  cavity  covers  such  a 
small  part  of  the  head  of  the  humerus 
that,  in  extreme  degrees  of  abduction, 
extension,  or  flexion,  any  force  trans- 
mitted through  the  shaft  of  the  bone  is 


Posterior. 


/  Subglenoid   (uncommon). 

.,'  Erecta  (very  rare). 

(Subtricipital. 

\  Subacromial    (rare). 

1^ Subspinous  (very  rare). 

Upward Supraglenoid   (very  rare). 

In  the  anterior  dislocations  the  dis- 
placement is  also  more  or  less  downward 
(and,  of  course,  inward),  and  in  the  down- 
ward ones  it  is  usually  also  forward  and 
inward.  Thus,  the  two  classes  merge 
into  each  other.  The  term  "subglenoid" 
is  restricted  to  those  cases  in  which  the 
head  of  the  bone  is  very  low,  others  of 
this   class   being   called    "subcoracoid." 


DISLOCATIONS.    SHOULDER. 


573 


The  accompanying  figure  (Fig.  4)  will 
demonstrate  the  different  positions  as- 
sumed by  the  head  of  the  bone  in  the 
anterior-and-downward  dislocation. 

Anterior  Dislocations.  —  The  sub- 
divisions of  this  variety  are  dependent 
on  the  increasing  amount  of  inward  dis- 
placement of  the  head  of  the  bone,  and 
grow  less  frequent  in  the  same  order; 
namely,  subcoracoid,  intracoracoid,  and 
subclavicular. 

Subcoracoid.  —  The  head  of  the  hu- 
merus lies  beneath  the  coracoid  process, 
in  contact  with  it  or  at  a  variable  dis- 
tance— a  finger's  breadth  at  most — below 
it.  The  head  may  be  displaced  inward 
until  three-fourths  of  its  diameter  lies  to 
the  inner  side  of  the  process  (farther  in- 
ward would  be  subcoracoid)  or  it  may  be 
simply  balanced  on  the  anterior  edge  of 
the  glenoid  fossa.  The  elbow  hangs  away 
from  the  side  and  the  deltoid  fullness  of 
the  shoulder  is  lost  (Fig.  5).  The  axis 
of  the  humerus  is  sure  to  pass  to  the  in- 
Qer  side  of  the  glenoid  fossa,  and  palpa- 
tion reveals  the  absence  of  the  usual 
bony  resistance  below  the  outer  side  of 
the  acromion,  and  the  presence  of  an 
abnormal  resistance  below  the  coracoid 
process,  in  the  axilla,  which  partakes  of 
rotary  movements  communicated  to  the 
arm.  Voluntary  movement  is  usually 
lost.  Passively  the  arm  can  be  abducted, 
but  not  adducted;  so  that  the  elbow 
touches  the  chest,  while  the  fingers  rest 
on  the  opposite  shoulder.  Measurement 
in  abduction  shows  shortening. 

The  diagnosis  is  usually  easily  made  by 
finding  the  glenoid  cavity  empty,  the 
head  of  the  bone  beneath  the  coracoid, 
and  by  eliciting  the  above-mentioned 
sign.  If  there  be  fracture  of  the  ana- 
tomical neck  the  head  will  not  partici- 
pate in  movements  imparted  to  the  shaft, 
and  crepitus  can  usually  be  elicited. 

Causes. — Direct  violence,  by  a  blow 


under  the  shoulder,  indirect,  as  by  a  fall 
upon  the  hand;  by  leverage  in  forcible 
abduction  and  outward  rotation;  or  by 
muscular  action  in  any  of  the  above 
ways. 

Pathology. — The  capsule  is  torn  at  its 
inner  and  lower  portion,  or,  more  rarely, 
stripped  up,  and  with  it  may  be  torn  the 
circumflex  nerve,  the  posterior  circum- 
flex artery,  and  subscapularis  (Fig.  6). 
In  "typical"  cases  the  outer  and  upper 
portions  of  the  capsule  remain  untorn 
and  aid  in  determining  the  abduction. 


Fig.    5. — Subcoracoid   dislocation    of   the   left 
shoulder.     [Stimson,  "Dislocations.") 

The  supraspinatus,  infraspinatus,  and 
teres  minor  may  be  torn  away  (in  decreas- 
ing order  of  frequency)  from  the  great 
trochanter  or  there  may  be  avulsion  of 
more  or  less  of  the  trochanter  itself. 
With  avulsion  of  the  trochanter  the  ten- 
don of  the  long  head  of  the  biceps  may 
slip  to  the  outer  side  of  the  bone  and 
oppose  reduction  (rarely).  This  tendon 
may  also  be  torn.  The  head  of  the 
humerus  is  often  bruised  and  ground  by 
impact  with  the  edge  of  the  glenoid 
cavity,  which,  in  turn,  is  splintered. 


574 


DISLOCATIOXS.    SHOULDER.    TKEATMENT. 


Treatment.  —  In  uncomplicated  cases 
reduction  is  usually  easy  by  Kocher's 
metliod,  as  follows: — 

The  elbow  is  flexed  to  a  right  angle 
and  pressed  closely  to  the  side;  then  the 
forearm  is  turned  as  far  as  possible  away 
from  the  trunk, — external  rotation  of  the 
arm  (Fig.  7).  Maintaining  the  external 
rotation,  the  elbow  is  carried  well  for- 
ward and  upward, — flexion  of  the  arm 
(Fig.   8);    and  finally  the  hand  swept 


After  a  long,  steady  pull,  manual  or  elas- 
tic, the  deltoid  may  yield  and  allow  the 
head  of  the  bone  to  be  pushed  back  into 
place.  Or,  after  a  few  moments  of  trac- 
tion, the  arm  is  violently  adducted  over 
the  closed  fist  in  the  axilla  (this  is  safer 
than  the  heel).  If  anfesthetics  are  used 
all  of  these  violent  measures  should  be 
executed  very  cautiously. 

Dr.  Cole  suggests  a  method  which  he 
claims  is  successful  in  a  large  number  of 


Fig.  6. — Subcoracoid  dislocation  on  a  cadaver,  showing  rupture  of  lower  part 
of  subseapularis.     (B.  Anger;   Stimsoti,  "Dislocntions,") 


over  until  it  touches  the  chest, — inward 
rotation  (Fig.  9), — the  elbow  being  si- 
multaneously lowered.  Anesthetics  may 
or  may  not  be  necessary.  If,  after  the 
"first  movement,"  the  head  does  roll  out 
in  front  of  and  below  the  acromion,  the 
attempt  will  fail.  Direct  manipulation 
of  the  head  may  be  of  assistance. 

If  Kocher's  method  fail,  traction 
•downward  and  outward  (never  upward 
and  outward,  on  account  of  the  danger 
of  lacerating  the  vessels)  should  be  tried. 


cases.  The  surgeon,  standing  by  the 
patient's  side,  holds  the  arm  abducted 
and  the  elbow  flexed,  and,  while  distract- 
ing the  patient's  attention,  gently  oscil- 
lates the  arm.  As  the  deltoid  is  seen  to 
relax,  a  sharp  blow  is  delivered  into  the 
fold  of  the  elbow  and  the  arm  rotated 
sharply  outward,  thus  rolling  the  bone 
into  place. 

If  judicious  attempts  at  reduction  by 
these  methods  fail,  even  under  anais- 
thesia,  an  open  arthrotomy  should  be 


DISLOCATIONS.    SHOULDEIt.    TREATilENT. 


575 


done  for  the  purpose  of  discovering  and 
removing  the  obstacle  to  reduction. 
In  intracoracoid  dislocations  the  head 


Fig.  7. — Kocher's  mptliod  of  reduction  by 
manipulation.  First  movement,  outward  rota- 
tion. (A^ppi,  "American  Text-took  of  Sur- 
gery.") 

is  displaced  farther  inward  and  the  symp- 
toms are  those  of  the  subcoracoid,  except 
that  the  head  of  the  humerus  is  felt 
farther   displaced    and   the    shoulder   is 


Fig  8  — Kocher  s  method  of  reduction.  Sec- 
ond mo\ement  ele\ation  of  elbow  {Appi, 
"Amci  ican  Tcxtlonlx  of  Surgery.") 

more  flattened.  The  arm  may  be  fixed 
in  horizontal  abduction.  The  cause  of 
this  particular  dislocation  is,  as  a  rule. 


an  unusual  amount  of  laceration  of  the 
capsule  and  subscapularis,  which  allows 
the  head  of  the  bone  to  slip  higher  into 
the  axilla.  Keduction  by  outward  trac- 
tion is  easy  unless  the  subscapularis  or 
a  torn  portion  of  the  capsule  intervene. 
In  such  cases  operation  is  the  only  re- 
course. 

In  subclavicular  dislocations  the  same 
forces  acting  more  energetically  force  the 
head  of  the  bone  up  under  the  clavicle. 

Downward  dislocations  include  all 
cases  in  which  the  head  of  the  bone  lies 


Fig.  9, — Kooher's  jiiftliod  vl  reduction. 
Third  movement,  inward  rotation  and  lower- 
ing of  elbow.  {Appi,  "American  Textbook  of 
Surgery.") 

below  the  glenoid  fossa.  In  subtricipital 
dislocation,  of  which  one  case  is  recorded, 
the  head  of  the  humerus  was  displaced 
secondarily  backward  and  upward  be- 
hind the  long  head  of  the  triceps. 

Subglenoid  Dislocations.  —  The  symp- 
toms are  those  of  subcoracoid  disloca- 
tion; but  abduction  and  flattening  of 
the  shoulder  more  marked.  The  head 
of  the  bone  is  palpable  below  its  socket. 
The  upper  part  of  the  greater  tuberosity 
is  habitually  torn  awav.    The  usual  cause 


576 


DISLOCATIOXS.    SHOULDER.    TKEATHENT. 


is  forcible  abduction  follo-n-ed  by  rota- 
tion or  impulsion. 

Treatment. — Traction  in  moderate  ab- 
duction with  direct  pressure. 

Litxatio  Euda. — Yery  rarely,  by  forc- 
ible elevation  of  the  arm  the  head  of  the 
bone  is  displaced  so  far  downward  that 
the  extremity  maintains  its  erect  posi- 
tion. It  is  reduced  by  upward  traction 
until  the  head  falls  into  place. 

Posterior  Dislocations.  —  The  two  va- 
rieties differ  only  in  the  extent  of  dis- 
placement. 

Symptoms. — The  arm  is  adducted  and 
rotated  in,  the  elbow  being  directed 
slightly  forward.  The  shoulder  is  flat 
in  front  and  full  behind  (when  the  head 
of  the  bone  may  be  felt).  Passive  motion 
is  restricted,  volxmtary  motion  absent. 

The  cause  is  direct  pressure  outward 
and  backward,  or  the  pressure  exerted 
in  the  same  direction  along  the  adducted 
and  inward-rotated  humerus. 

The  outer  side  of  the  capsule  is  torn 
and  the  external  and  internal  scapular 
muscles  more  or  less  lacerated  or  avulsed 
with  fragments  of  the  tuberosities.  The 
head  of  the  bone  lies  on  the  outer  edge 
of  the  glenoid  fossa,  or  farther  back  be- 
neath the  spine  of  the  scapula,  or  on  the 
infraspinatus. 

Treatment.  —  Kcduction  is  accom- 
plished by  traction  and  direct  pressure 
forward.  Avulsion  of  the  subscapularis 
makes  recurrence  probable.  Unreduced 
dislocations  backward  are  accompanied 
by  an  unusual  amount  of  disability. 

UpvMrd  Dislocations. — These  are  ex- 
tremely rare.  The  head  of  the  bone  is 
forced  upward  between  the  coracoid  and 
acromion,  usually  to  above  the  clavicle. 
The  arm  is  almost  immobilized  in  adduc- 
tion and  slight  extension.  Reduction 
may  be  efFocted  by  downward  traction. 

Complications  of  Dislocations  of  the 
Shoulder.  —  Compound  dislocations  are 


very  rare,  and  are  commonly  caused  by 
direct  violence.  The  skin-wcund  is  usu- 
ally in  the  axilla.  Aside  from  ooniplica- 
tions  which  may  exist  not  dependent  on 
the  dislocation,  the  great  dangers  are 
from  laceration  of  the  main  arteries  (fre- 
quent) or  nerves  (unusual)  and  from  sup- 
puration. The  treatment  consists  of  en- 
larging the  wound  until  the  extent  of 
damage  can  be  fully  appreciated  and,  as 
far  as  possible,  repaired.  Meanwhile  the 
wound  should  be  thoroughly  irrigated 
with  "normal"  salt  solution.  The  dislo- 
cation may  now  be  easily  reduced.  In 
most  cases  thorough  drainage  should  be 
provided  for,  and  in  some  cases  it  may  be 
advisable  to  excise  the  head  of  the 
humerus  to  this  end  to  oppose  ankylosis. 
Fractures  of  the  various  bony  promi- 
nences of  the  scapula  and  humerus  have 
commonly  a  purely  pathological  impor- 
tance. Fractures  of  the  anatomical  or 
surgical  neck  of  the  humerus  are  impor- 
tant, but  often  difficult  to  diagnose.  The 
diagnostic  points  of  fracture  of  the  ana- 
tomical neck  are  the  recognition  of  the 
head  in  the  axilla  and  its  failure  to  move 
with  the  shaft,  the  maintenance  of 
near-by  normal  range  of  motion  and  the 
normal  position  of  the  greater  tuberosity. 
Crepitus  may  sometimes  be  elicited.  In 
fracture  of  the  surgical  neck  the  signs  are 
quite  the  same,  except  that  the  tuber- 
osity is  displaced  with  the  head,  and, 
with  it,  fails  to  move  with  the  shaft,  and 
crepitus  is  more  easily  elicited.  In  either 
case  the  upper  fragment  may  be  reduc- 
ible by  direct  manipulation.  This  fail- 
ing, if  the  fragments  can  be  approxi- 
mated, the  arm  may  be  immobilized  for 
three  or  four  weeks  in  an  appropriate 
position  with  the  hope  of  obtaining 
union  and  effecting  reduction  at  the  end 
of  that  time  by  manipulation.  But  the 
better  plan  ia  probably  to  do  an  open 
arthrotomy  and  reserve  the  upper  frag- 


DISLOCATIOXS.    SHOULDER.     UNREDUCED.    ELBOW. 


577 


ment  except  in  such  fractures  of  the 
surgical  neck  as  can  be  reduced,  and  to 
this  end  the  use  of  a  strong  right-angled 
hook  inserted  into  a  hole  drilled  at  the 
lower  end  of  the  upper  fragment,  may  be 
of  great  service  (McBurney).  Or  a  fairly- 
useful  false  joint  may  sometimes  be  ob- 
tained at  the  point  of  fracture. 

Injuries  to  Vessels  and  Nerves. — 
The  axillary  itself  is  very  rarely  rupt- 
ured, and  hence  the  radial  pulse  may 
persist,  even  though  there  be  serious 
damage  to  the  arteries  about  the  joint. 
This  damage  is  usually  due  to  ill-advised 
attempts  at  reduction,  and  is  recognized 
by  the  rapid  extravasation  of  blood  down 
the  arm  and  into  the  axilla.  Treatment 
is  by  pressure,  ligature  of  the  axillary  or 
subclavian,  or  disarticulation  of  the 
shoulder.  The  mortality  is  very  high. 
The  circumflex  nerve  is  often  torn,  with 
a  resulting  temporary  or  permanent  dis- 
ability of  the  deltoid  and  anaesthesia  of 
the  shoulder. 

Treatment  of  Old  Unreduced  Dis- 
locations. —  If  the  dislocation  cannot 
be  reduced  after  loosening  adhesions  by 
forcible  (yet  judicious)  rotation  and  trac- 
tion, operation  is  advisable  for  reduction 
by  division  of  the  soft  parts,  or  for  exci- 
sion of  the  head  of  the  bone.  A  very 
serviceable  joint  may  be  obtained  by 
the  latter  method;  but  as  the  line  of  di- 
visions of  the  bone  runs  below  the  tuber- 
osities, rotation  is  practically  lost. 

Habitual  dislocation  has  been  cured 
by  reefing  the  anterior  portion  of  the 
capsule.  Eieard  advises  the  usual  an- 
terior incision  between  the  deltoid  and 
pectoralis,  supplemented  by  a  horizontal 
one  along  the  clavicle  and  dissection  back 
of  the  anterior  part  of  the  deltoid. 

Dislocations  of  the  elbow  stand 
second  in  order  of  frequency,  and  are 
most  common  in  persons  under  twenty- 
five.    Among  the  great  variety  of  forms 


of  dislocations  of  both  bones,  the  back- 
ward are  by  far  the  most  frequent. 

The  divisions  and  subdivisions  are  as 
follows: — 

1.  Dislocations  backward  : 
and  outward, 
and  inward. 

2.  Lateral  dislocations  : 

Incomplete! '"7"'-, 
'         1.  outward. 

Dislocations  of    I         ^        i  ^    f      »        i 
both    Bones  ;         Complete  |  outward. 

of  the  Fore-  ^  3.  Forward  dislocations  : 
arm  Incomplete  (first  degree). 

Complete  (second  degree). 
"With  fracture  of  the  olec- 
ranon. 
4.  Divergent  dislocations. 
Antero-posterior. 
Lateral. 

/  Backward  f^°«^'j;Pl<^t«    ^^^' 
Dislocations!     wl'''*"    ^ o ". P 1  e t e    (second 
of    Ulna)  ^     '•^eree). 

Alone  1  b_.,(.1j^j,„i   and  Outward  (behind 

the  HMlius). 
Inward  (one  case). 


1.  Backward. 

2.  Outward. 

3.  Forward. 


Dislocations  \ 

,,     ,  •         ;  4.  By  elonjration  (the  subluxation 

K  a  d  1  us  \         •  -    -   -'^-  ^ 

Alone 


of  children). 
With  fracture  of  the 
ulna. 


Dislocations  of  Both  Bones  Bacl'ward. 
— The  inward  and  outward  subvarieties 
are  of  no  practical  importance. 

Si/mpto7ns. — The  elbow  is  swelled  and 
partly  flexed.  The  olecranon  may  be  felt 
displaced  backward  from  the  epicondyles 
and  the  head  of  the  radius  may  be  recog- 
nized behind  the  external  epicondyle  as 
a  bony  point  which  rotates  with  the  fore- 
arm. The  trochlear  surface  may  be 
prominent  in  the  bend  of  the  elbow;  the 
tendon  of  the  biceps  behind.  Passive 
flexion  and  extension  are  moderate. 
There  is  abnormal  lateral  mobility  in  full 
extension. 

The  cause  is  most  commonly  a  fall 
upon  the  outstretched  hand  forcing  the 
two  bones  backward.  The  coronoid  proc- 
ess of  the  ulna  is  either  broken  or  lifted 
•37 


578 


DISLOCATIONS.    ELBOW.    TREATMENT. 


over  the  trochlear  surface  by  hyperexten-  I 
sion  or  by  abduction,  which  increases  the 
normal  outward  deviation  of  the  fore- 
arm and  a  twist  which  swings  the  process 
downward  and  then  backward. 

Pathology. — The  internal  lateral  liga- 
ment is  torn,  and  the  external  one  either 
torn  or  stripped  away  with  the  perios- 
teum from  the  external  condyle.  Hence, 
in  old  dislocations  reduction  is  effectually 
prevented  by  the  mass  of  callus  that 
forms  beneath  this  elevated  periosteum 
behind  the  external  condyle.  The  front 
of  the  capsule  is  torn,  the  epitrochlea 
(internal  epicondyle)  may  be  broken  by 
muscular  action,  or  the  muscles  attached 
to  it  may  be  ruptured.  Fractures  of  the 
head  of  the  radius  and  coronoid  process 
are  rare.  The  latter,  however,  does  not 
interfere  with  the  action  of  the  brachi- 
alis  anticus,  as  that  muscle  is  attached 
to  the  base  of  the  process:  a  part  not 
interested  in  the  fracture. 

Treatment. — Forcible  flexion  is  to  be 
condemned  as  unscientific  and  less  likely 
to  succeed  than  pressvire  on  the  dislo- 
cated bones  combined  with  traction  of 
the  forearm  in  moderate  extension  or 
h}'perextension.  Usually  the  dislocation 
is  easily  reduced.  Sometimes  anesthet- 
ics are  necessary.  After  reduction  the 
limb  should  be  immobilized  by  bandages 
and  a  sling  for  about  three  weeks,  after 
which  mild  massage  and  active  motion 
will  gradually  remove  the  stiffness. 
Early  passive  motion  will  not  hasten  the 
result,  and  may  even  increase  the  ex- 
cessive production  of  callus  which,  in 
children,  sometimes  goes  on  even  after 
reduction  and  may  cause  serious  limita- 
tion to  the  motion  of  the  joint. 

Lateral  Dislocations. — Incomplete  dis- 
locations in  either  direction  are  said  to 
be  frequently  overlooked  or  mistaken  for 
fractures.  The  cause  of  lateral  disloca- 
tions is  usually  a  fall  upon  the  hand  by 


which  the  normal  outward  angle  at  the 
elbow  is  increased  by  tearing  of  the  in- 
ternal lateral  ligament  and  a  downward 
movement  of  the  ulna,  directly  away 
from  the  trochlea.  The  head  of  the 
radius  then  glides  either  outward  or  in- 
ward, as  the  case  may  be,  the  ulna  fol- 
lowing. 

In  incomplete  inward  dislocations  the 
forearm  is  pronated  and  slightly  flexed; 
its  long  axis  parallel  to  and  a  little  to  the 
inner  side  of  that  of  the  arm.  The  olec- 
ranon and  external  condyle  are  promi- 
nent, and  the  head  of  the  radius  can  be 
felt  displaced  downward  and  inward, 
resting  below  the  trochlea  (the  greater 
sigmoid  cavity  of  the  ulna  embraces  the 
epitrochlea).  Flexion  and  extension  are 
but  little  interfered  with.  Eeduction  is 
made  by  traction  and  direct  pressure. 
In  unreduced  cases  there  is  very  little 
disability,  and  operative  interference  is 
probably  inadvisable. 

Incomplete  Outivard  Dislocations.  — 
The  forearm  is  pronated  and  slightly 
flexed,  and  its  long  axis  is  to  the  outer 
side  of  and  parallel  to  that  of  the  arm  or 
else  in  abduction.  The  ulna  is  displaced 
so  that  the  central  ridge  of  the  greater 
sigmoid  cavity  has  passed  beyond  the 
outer  rim  of  the  trochlea;  the  radius  lies 
partly  below  or  entirely  beyond  the  ex- 
ternal condyle.  The  internal  condyle 
and  olecranon  are  prominent. 

Treatment. — The  ridge  of  the  sigmoid 
cavity  must  be  unlocked  from  the  groove 
between  the  trochlea  and  capitellum. 
This  is  done  by  traction  or  hypercxten- 
sion  (or  by  abduction,  if  the  head  of  the 
radius  rests  below  the  external  condyle 
and  can  be  used  as  a  fulcrum).  Then  the 
bones  are  pushed  easily  into  place.  The 
broken  epitrochlea  may  lodge  in  the 
groove  of  the  trochlea  and  efFcctually 
prevent  reduction.    Even  if  the  disloca- 


DISLOCATIONS.     ARM. 


579 


tion  be  not  reduced,  tlie  joint  may  be 
quite  useful. 

Complete  outward  dislocation  occurs 
in  three  forms.  In  the  simplest  form  the 
bones  of  the  forearm  are  displaced  di- 
rectly outward,  the  inner  edge  of  the 
olecranon  resting  against  the  outer  side 
of  the  external  condyle.  If,  now,  the 
forearm  is  flexed  and  strongly  pronated, 
the  second  form  (subepicondylar)  is  pro- 
duced, in  which  the  anterior  surface  of 
the  ulna  looks  inward  and  its  sigmoid 
cavity  embraces  the  outer  side  of  the 
external  condyle,  while  the  radius  lies 
above  it,  with  its  head  in  front  of  the 
epicondylar  ridge.  In  the  third  form 
(supra-epicondylar)  the  dislocated  bones 
are  moved  still  further  upward  and  back- 
ward, so  that  their  articular  surfaces  lie 
external  to  and  behind  the  supinator 
ridge.  Reduction  is  usually  easy,  owing 
to  the  extensive  laceration  to  ligaments; 
but,  even  if  unreduced,  the  elbow  re- 
mains fairly  strong  and  mobile. 

Forward  Dislocation. — This  rare  in- 
jury is  usually  caused  by  direct  trauma 
to  the  back  of  the  flexed  elbow.  The 
olecranon  was  broken  in  about  a  third 
of  the  cases.  If  this  is  the  case,  the  ulna 
and  radius  are  displaced  forward  and  up- 
ward in  the  anterior  surface  of  the 
humerus;  but,  if  the  olecranon  remains 
intact,  it  may  rest  on  the  trochlea,  or, 
the  triceps  being  torn  away,  it  may  pass 
to  the  front  of  the  humerus.  Reduction 
by  traction  appears  to  liave  been  easily 
accomplished. 

Divergent  Dislocations  of  the 
Radius  and  Flna. — In  the  antero-pos- 
terior  variety  the  ulna  lies  behind  and 
the  radius  in  front  of  the  humerus;  in 
the  transverse  the  ulna  is  displaced  in- 
ward and  the  radius  outward.  The  usual 
cause  seems  to  be  abduction  followed  by 
internal  rotation  and  impulsion.    Reduc- 


tion has  failed   in   one-quarter  of  the 
cases. 

Dislocation  of  the  Ulna  Alone. — 
The  forearm  is  usually  extended  and  ad- 
ducted.  Flexion  is  painful;  rotation 
free.  The  trochlea  is  prominent  in  front 
and  the  olecranon  behind,  while  the  head 
of  the  radius  remains  in  place.  The  cause 
of  the  injury  appears  to  be  hyperexten- 
sion  or  abduction,  followed  by  adduction 
and  inward  rotation.  The  rational 
method  of  reduction  is  by  supination, 
abduction,  and  hyperextension  (von 
Pitha). 

Dislocation  of  the  Radius  Alone. 
— Of  the  dislocations  backward,  outward, 
and  forward  the  last  is  the  most  frequent, 
being,  in  fact,  of  not  unusual  occur- 
rence in  connection  with  a  fracture  of 
the  shaft  of  the  ulna  from  a  fall  upon  the 
hand.  The  head  of  the  bone  is  displaced 
upward  in  front  of  the  external  condyle. 
The  orbicular  and  anterior  ligaments  are 
torn.  Abduction  is  possible,  while  supi- 
nation, flexion,  and  adduction  are  all 
limited.  Adduction  and  pressure  ap- 
pears to  be  the  best  method  of  reduction; 
but  the  orbicular  ligament  may  be  inter- 
posed and  require  operative  interference. 
The  backward  and  outward  dislocations 
are  very  rare.  They  necessitate  a  fract- 
ure of  the  ulna  or  a  rupture  of  the  inter- 
osseous membrane. 

The  downward  dislocation  (dislocation 
by  elongation,  subluxation  of  young  chil- 
dren) is  of  frequent  occurrence.  The 
clinical  history  is  quite  characteristic:  a 
child,  usually  under  three  years  of  age, 
is  pulled  by  the  hand;  it  cries  out,  and 
refuses  to  use  the  limb,  which  hangs  with 
the  forearm  partly  flexed  and  pronated. 
The  region  of  the  head  of  the  radius  is 
sensitive  to  pressure,  and  sometimes  an 
interval  can  be  felt  between  the  radius 
and  the  condyle.  All  passive  motions, 
except  supination,  are  free.    On  forcible 


580 


DISLOCATIONS.    AKM.    WKIST.    HAND. 


Bupination  a  slight  click  may  be  felt  and 
the  symptoms  are  at  once  relieved.  Du- 
verney's  theory  of  downward  displace- 
ment with  interposition  of  the  annular 
ligament  is  most  in  accord  with  the  facts. 
Old  Uneeduced  Dislocations  of 
THE  Elbow. — Adhesions  and  new  bone 
formation  verj'  soon  immobilize  the  joint. 
If  this  immobilization  occurs  in  exten- 
sion, the  position  may  be  improved  by 
forcible  flexion,  with  or  without  fracture 
of  the  olecranon.  A  more  accurate 
method,  however,  and  one  likely  in  many 
cases  to  afEord  fairly-good  functional  re- 


Fig.  10. — Diagrammatic,  to  indicate  the  de- 
formity in  [A)  dislocation  of  the  wrist  back- 
ward and  (/?)  CoUes's  fracture  of  the  radius. 
{SHmaon.) 

suits,  is  arthrotomy.  The  chief  obstacle 
to  reduction  will  be  found  to  be  the  new 
bone  in  the  great  sigmoid  cavity.  This 
may  be  removed  and  adhesions  divided 
through  two  lateral  incisions,  or  a  U- 
shaped  incision  with  division  of  the  tri- 
ceps or  olecranon. 

Dislocations  of  tue  Lower  Radio- 
Ulnau  Joint. — The  ulna  is  spoken  of  as 
the  dislocated  bone.  It  may  be  dislo- 
cated forward  or  backward.  The  latter 
variety  is  caused  by  exaggerated  prona- 
tion, and  the  former  by  direct  trauma. 
Both  are  easily  reduced. 


Dislocations  of  the  Carpus  from 
THE  Radius. — These  may  be  complete  or 
incomplete;  forward,  backward,  or  out- 
ward. In  the  incomplete  form  the  cunei- 
form maintains  its  relations  to  the  tri- 
angular fibrocartilage,  while  the  scaphoid 
and  semilunar  are  dislocated  from  the 
radius.  In  one  case  the  semilunar  alone 
was  not  displaced  (backward).  These 
dislocations  may  be  complicated  by  fract- 
ure of  the  anterior  or  posterior  ("Bar- 
ton's fracture")  lip  of  the  radius;  but 
this  in  no  way  complicates  the  treat- 
ment and  is  a  purely  secondary  matter. 

The  more  common  Colles  fracture  of 
the  lower  end  of  the  radius  was  long  con- 
founded with  backward  dislocation.  The 
differential  diagnosis  is  easily  made  by 
attention  to  the  relations  of  the  styloid 
process  of  the  radius  with  that  of  the 
ulna  and  with  the  projecting  mass  on  the 
back  of  the  wrist  (Fig.  10).  Reduction 
in  either  case  is  made  by  dorsal  flexion 
and  direct  pressure,  and  after  reduction 
the  diiferential  diagnosis  is  easy. 

The  spontaneous  forward  dislocation 
of  Madeburg  occurs  slowly  in  adolescents 
as  the  result  of  absorption  of  the  anterior 
part  of  the  articular  surface  of  the  radius. 
The  ulna  is  abnormally  prominent; 
dorsal  flexion  is  limited. 

Dislocations  of  the  Carpal  Bones. 
Dislocations  have  been  reported  of  each 
of  the  carpal  bones  except  the  cuneiform. 
If  the  bone  cannot  be  pressed  into  place, 
and  gives  rise  to  annoying  symptoms,  it 
had  bettor  be  removed. 

A  few  dislocations  of  the  second  row 
of  carpal  bones  upon  the  first  have  been 
reported. 

CARPo-METAOAnrAL  Dislocations. — 
The  first  metacarpal  is  the  one  most 
commonly  dislocated;  the  dislocation  is 
usually  backward  and  incomplete.  The 
base  of  the  dislocated  bone  forms  a  dis- 
tinct  prominence   on   the   back   of  the 


DISLOCATIONS.    FIXGERS. 


581 


hand;  this  is  readily  reduced,  but  as 
readily  recurs.  To  prevent  recurrence, 
extension  of  the  finger  (and  also  abduc- 
tion, if  it  be  the  thumb)  and  direct  press- 
ure on  the  head  of  the  bone  must  be 
maintained  by  a  dorsal  splint  for  one 
or  two  weeks.  Habitual  dislocations  of 
these  joints  are  often  quite  painful. 


Fig.   11. — Simple  complete  dislocation   of  the 
thumb.     (Farabciif.) 

Dislocations  of  the  Thumb  and 
FlNGEHS, — Metacarpo-Phalangeal  Dislo- 
cations of  the  Thumb. — Lateral  (one  case) 
and  forward  dislocations  present  no  es- 
pecial points  of  interest.  The  latter  are 
easily  reduced  by  hyperflexion  and  trac- 
tion. Backward  dislocations  of  this 
joint,  however,  have  long  been  the  sub- 
ject of  controversy,  and  are  treated  in 
some  of  our  latest  text-books  in  a  manner 
none  too  accurate.  This  dislocation  may 
be  incomplete,  complete,  or  complex.  In- 
complete backward  dislocations  may  be 
produced  voluntarily  by  many  young 
persons.  It  is  reduced  at  will.  In  the 
complete  form  the  phalanx  is  carried 
backward  and  upward  on  the  dorsum  of 
the  metacarpal,  usually  by  forced  exten- 
sion, the  anterior  ligament  is  torn  away 
from  the  metacarpal  bone  and  drawn 
backward  with  its  sesamoid  bones  along, 
and  even  past,  the  articular  surface  of 
the  head  of  the  metacarpal,  while  the 
tendon  of  the  long  flexor  slips  to  one 
side  of  the  head,  usually  the  inner,  al- 
though it  may  exceptionally  remain  in 


place.  The  first  phalanx  is  in  extension 
at  a  right  angle,  the  terminal  phalanx  in 
flexion,  and  the  head  of  the  metacarpal 
prominent  in  the  thenar  eminence  (Fig. 
11). 

In  the  complex  form  (produced  from 
the  complete  by  forced  flexion  of  the 
thumb)  the  glenoid  ligament,  and  the 
two  sesamoid  bones  with  it,  are  turned 
upward  so  as  to  lie  between  the  phalanx 
and  the  head  or  dorsum  of  the  meta- 
carpal. The  thumb  is  in  straight  exten- 
sion, parallel  and  posterior  to  the  meta- 
carpal; its  base  can  be  felt  as  a  promi- 
nence behind,  and  the  head  of  the  meta- 
carpal protrudes  in  front.  The  sesamoid 
bones  stand  at  a  right  angle  to  the  ar- 
ticular surface  of  the  phalanx,  and  can- 
not be  folded  under  it,  thus  offering  a 
great — often  insurmountable — obstacle 
to  reduction.  The  essential  point  of  re- 
duction, therefore,  is  to  avoid  the  trans- 
formation of  the  complete  into  the  com- 
plex form.  The  extension  must  be  main- 
tained or  even  increased  and  the  thumb 
pressed  bodily  downward  until  the  an- 
terior edge  of  its  base,  following  the 
glenoid  ligament,  overlaps  the  articular 
surface  of  the  metacarpal,  when  it  can 
he  turned  into  place  by  flexion.  If  this 
fail,  a  combination  of  rotation  with  the 


Fig.  1-2.— Complex  dislocation,     {larabruf.) 

downward  pressure  may  succeed:  a  sort 
of  unbuttoning  of  the  head  of  the  meta- 
carpal from  the  grasp  of  the  glenoid  liga- 
ment and  the  attached  heads  of  the  short 
flexor.  If,  however,  the  dislocation  has 
become  complex  by  the  interposition  of 
the  glenoid  ligament,  the  same  method 
may  yet  succeed;  but  much  more  for- 


582 


DISLOCATIONS.    PEL^aS  AXD  COCCYX.    HIP. 


cible  downward  traction  is  necessary  to 
carry  the  edge  of  the  ligament  over  the 
end  of  the  metacarpal  bone  ahead  of  the 
phalanx  before  instituting  flexion.  If 
all  manipulations  fail,  the  joint  must  be 
opened  through  a  longitudinal  anterior 
incision,  and  the  centre  of  the  glenoid 
ligament  nicked  deeply  enough  to  allow 
it  to  be  drawn  over  the  head  of  the  meta- 
carpal, after  which  the  dislocation  may 
be  readily  reduced. 

Metacarpo-phaJangeal    dislocations    of 


Fig.    13. — Doi6al    dislocation    of    femur. 
{Cooper.) 

the  fingers  present  the  same  features  as 
those  of  the  thumb,  save  that  they  usu- 
ally have  no  sesamoid  bones. 

Dislocation  of  the  'phalanges  may  occur 
in  any  direction.  Reduction  is  usually 
ea.5y,  though  it  is  possible  that  the  thick 
anterior  ligament  may  be  interposed,  as 
in  the  metacarpo-phalangeal  joint. 

Dislocations  of  the  Pelvis  and 
Coccyx. — Dislocation  of  the  pubic  and 
sacro-iliac  symphyses  occurs  in  connec- 
tion with  fracture  of  the  pelvis,  the  symp- 


toms and  treatment  of  which  it  does  not 
materially  complicate. 

The  coccj'x  may  be  dislocated  forward 
or  backward.  The  pain  is  usually  in- 
tense. Diagnosis  and  reduction  are  ef- 
fected by  rectal  tottch.  The  tendency  to 
recurrence  can  only  be  remedied  by  exci- 
sion of  the  bone. 

Dislocations  of  the  Hip.  —  These 
form  from  2  to  10  per  cent,  of  all  dislo- 
cations; they  occur  at  all  ages  and  are 
more  common  in  men  than  in  women. 
The  head  of  the  femur  may  leave  its 
socket  in  any  of  the  four  principal  direc- 
tions, after  which  it  assumes  various  po- 
sitions by  secondary  displacement.  In 
"typical"  dislocations  the  Y-ligament  re  • 
mains  untorn  and  determines  the  char- 
acteristic attitude  of  the  limb  (Bigelow) 
Compound  dislocations  are  rare.  The 
varieties  are  as  follows: — 

C  "  Typical  "  ilovsal  (comprising  tlie 
Dislocations  |      iliac  and  "  iscliiatic, "  and  those 
Backward  1      "upon   the    doreuni  ilia"   and 
[      "  into  the  ischiatic  notch  "). 

C  Anterior  obliqne. 
Dislocations  J  Everted    dorsal    (comprisinf!:    the 
Back^Yard  I      "  suprasj)inons "   and    some    of 
[     the  ''supracotyloid"). 

Dislocations  Downward  /  Obturator, 
and  Inward  \  Perineal. 

Disloca  t  i  o  n  s  ^  ( Ilio-pectineal . 

Forward  >  Suprai)ul)ic  \  PuViic. 
and  Upward  J  [  Intrapelvic. 

Dislocations  directly  upward  (supracotyloid  or 

subspinous). 
Dislocations  downward  on  the  tuberosity  of  the 

ischium. 

Backward  Dislocations.  —  The  dorsal 
form  is  by  far  the  most  common  of  the 
dislocations  of  the  hip.  The  thigh  is 
adductcd,  rotated  inward,  and  more  or 
less  flexed;  so  that  the  knee  rests  upon 
the  front  of  the  opposite  thigh  when  the 
patient  is  recumbent,  and  there  is  appar- 
ent shortening  (Fig.  1 3).  The  upper  and 
outer  part  of  the  thigh  is  broadened,  and 
the  trochanter  is  above  N6]aton's  line  (a 


DISLOCATIONS.     HIP.    TKEAT.MEXT. 


583 


line  drawn  from  the  antero-superior  spine 
of  the  ilium  to  the  tuberosity  of  the 
ischium).  The  head  of  the  femur  may 
be  obscurely  felt  in  the  buttock. 

The  actual  shortening  cannot  easily  be 
determined  on  account  of  the  difficulty 
of  placing  the  two  limbs  in  symmetrical 
positions.  Voluntary  movement  and  fric- 
tion are  lost;  passive  flexion  and  adduc- 
tion alone  are  possible. 

The  characteristic  position  and  limita- 
tion of  motion  readily  distinguishes  the 
dislocation  from  a  fracture  of  the  neck 
of  the  femur. 

Etiology. — The  dislocation  is  usually 
produced  by  violence  transmitted  along 
the  shaft  of  the  femur  while  the  thigh  is 
flexed,  adducted,  and  rotated  inward;  or 
the  head  of  the  bone  may  be  thrown  out 
of  place  by  exaggerated  adduction,  in- 
ward rotation,  and  slight  flexion;  or, 
again,  the  dislocation  may  result  second- 
arily from  an  obturator  dislocation  by 
the  same  three  motions. 

Pathology. — The  head  of  the  bone  usu- 
ally tears  through  the  capsule  low  do^vn 
behind,  passes  below  and  then  upward 
behind  the  obturator,  and  rests  finally 
on  that  muscle  close  behind  the  acetabu- 
lum, or,  more  rarely,  it  leaves  its  socket 
higher  up,  pushes  the  obturator  ahead  of 
it  outward  or  upward,  and  lies  on  the 
edge  of  the  acetabulum  itself.  The  cap- 
sule is  irregularly  torn  behind,  the  liga- 
mentum  teres  is  ruptured,  the  quadratus 
femoris  and  gemelli  are  usually  torn,  the 
two  obturators  and  pyri  forms  less  fre- 
quently. Earely  the  head  of  the  bone 
rests  on  the  great  sciatic  notch  or  the 
dorsum  ilia.  The  edge  of  the  acetabulum 
may  be  shattered  and  the  head  of  the 
bone  split. 

Treatment.  —  The  surgeon  must  en- 
deavor to  relax  the  Y-ligament  and  other 
untorn  portions  of  the  capsule,  to  bring 
the  head  of  the  bone  opposite  the  rent 


in  the  capsule  (if  necessary)  and  then  to 
lift  or  pry  it  into  place.  To  do  this  the 
patient  is  laid  flat  on  his  back  and  the 
pelvis  steadied  by  an  assistant  or  by  the 
surgeon's  foot.  The  patient's  knee  is 
then  flexed  at  a  right  angle,  the  thigh 
rotated  inward  and  flexed  to  or  a  little 
beyond  a  right  angle,  and  then  lifted 
bodily  upward,  rotated  a  little  outward, 
and  extended  in  abduction.  The  lifting 
and  outward  rotation  should  replace  the 
bone  with  a  distinct  jump. 

Or  the  patient  may  be  laid  on  his  face 
on  a  table,  whose  edge  comes  just  above 
the  groin,  so  as  to  leave  the  lower  ex- 


Pifrifamis 


Oil.Int. 


Fig.  14. — Dislocation  below,  and  then  be- 
hind and  above,  the  obturator  internua. 
(Stimson.) 

tremities  dangling.  The  sound  limb  is 
now  held  horizontally  by  an  assistant, 
and  the  dislocated  one  allowed  to  hang 
vertically  downward.  The  surgeon 
grasps  the  ankle  of  the  dislocated  limb, 
flexes  the  knee  to  a  right  angle,  and, 
while  diverting  the  patient's  attention, 
swings  the  limb  gently  from  side  to  side. 
Under  the  influence  of  gravity  the  mus- 
cles soon  relax  and  the  bone  may  slip 
into  place  of  itself  or  aided  by  a  sharp 
quick  pressure  downward  on  the  calf. 

If  these  methods  fail,  ether  should  be 
administered  and  reduction  attempted 
several  times  by  the  first  method.  Fail- 
ing again,  try  traction  in  slight  flexion 
and  adduction,  aided  by  direct  pressure 
on  the  great  trochanter. 


584 


DISLOCATIONS.    HIP. 


If  the  limb  is  too  strongly  flexed  or 
too  soon  rotated  outward  the  dorsal  dis- 
location may  be  tranformed  into  a  thy- 
roid one.  If  this  occurs,  the  dislocation 
must  be  restored  to  its  original  form  by 
reversing  the  movements:  flexion  in  ab- 
duction and  outward  rotation,  followed 
by  adduction  and  rotation  inward. 

Everted  Dorsal  Dishcaiions.  —  If  the 
outer  branch  of  the  Y-ligament  is  rupt- 
ured, the  limitation  to  abduction  and 
outward  rotation  is,  in  great  part,  re- 
moved, and  the  head  of  the  bone  is  free 
to  rise  higher  than  before.  Hence,  when 
this  rupture  occurs,  if  the  head  remains 
behind  the  acetabulum  only  slight  flexion 
and  adduction  persist,  while,  if  it  has 
moved  upward  and  forward  near  to  or 
above  the  antero-inferior  spine  of  the 
ilium  (in  which  position  it  can  be  felt), 
there  will  be  extension,  abduction,  and 
slight  outward  rotation:  the  so-called 
everted  dorsal.  Eeduction  is  effected  by 
converting  the  dislocation  into  the  com- 
mon dorsal  form  and  treating  it  as  such. 

Anterior  Oblique  Dislocation.  —  In 
Bigelow's  one  reported  case  the  head  of 
the  bone  was  high  above  the  acetabulum 
and  the  limb  crossed  the  opposite  thigh, 
everted,  and  with  the  knee  extended. 
Reduction  as  for  everted  dorsal  disloca- 
tion. 

Dislocations  Downward  and  Inward. — 
In  both  the  obturator^or  thyroid — and 
perineal  varieties  the  head  escapes 
through  a  rent  in  the  lower  and  inner 
])art  of  the  capsule  to  lodge  on  the  ob- 
turator foramen,  or  to  proceed  farther 
and  rest  on  the  perineum.  In  either  case 
the  limb  is  flexed,  abducted,  and  rotated 
outward.  It  cannot  l)e  extended  and 
can  only  be  adducted  after  flexion.  The 
limb  is  shortened,  the  trochanteric  re- 
gion flattened,  and  adduction  tense.  The 
head  of  the  femur  may  Rometimos  be  felt 
on  the  foramen,  always  if  it  is  in  the  per- 


ineum, in  which  latter  case  the  abnor- 
mality of  the  position  of  the  limb  is  much 
greater.  Several  patients  are  reported  to 
have  walked  immediately  after  receiving 
a  thyroid  dislocation. 

The  common  cause  is  violence  received 
on  the  back  of  the  pelvis  while  the  thigh 
is  somewhat  flexed  and  abducted;  but  it 
may  be  extreme  abduction  alone.  In 
perineal  dislocations  the  laceration  of  the 
soft  parts  must  be  extensive. 

Eeduction  is  made  by  flexion  of  the 
hip  to  a  right  angle,  traction  with  adduc- 
tion, and  then  inward  (or  outward)  rota- 
tion while  lowering  the  knee.  Manipu- 
lation may  succeed  with  no  rotation  at 
all. 

Dislocations  Upward  and  Forward,  and 
Inward  and  Forward  (Suprapulic). — 
The  limb  is  extended,  markedly  everted, 
and  slightly  abducted.  The  head  of  the 
femur  is  commonly  to  be  felt  in  the  groin 
(ilio-pectineal  form)  or  may  be  above  the 
pubes.  The  psoas-iliac  and  the  great 
vessels  are  stretched  across  the  head  or 
may  be  ruptured.  The  head  of  the  bone 
may  have  left  the  socket  at  its  upper  and 
inner  part  by  hyperextension,  or  by  ab- 
duction and  outward  rotation,  or  the  dis- 
location may  be  secondary  to  an  ob- 
turator dislocation. 

lieduction. — The  head  is  to  be  drawn 
downward  past  the  pubic  ramus  by  di- 
rect traction  in  the  axis  of  the  limb  as 
it  lies;  then  flexion  is  instituted  while 
pressure  is  made  against  the  head  to  pre- 
vent its  moving  upward  again;  and  fi- 
nally inward  rotation  replaces  the  bone. 

Dislocations  Directly  Upward  {Supra- 
cotyloid). — In  the  few  recorded  cases  the 
bead  had  been  forced  directly  upward  and 
lay  just  Ijencatli  the  antero-inferior  spine 
of  the  ilium.  The  limb  was  everted  and 
abducted.  Some  of  the  patients  have 
been  able  to  walk  with  a  limp. 

These  cases  bear  a  close  resemlilance 


DISLOCATIONS.    KNEE.    TREATMENT. 


585 


to  everted  dorsal  dislocations.  Xo  defi- 
nite rules  for  reduction  have  been  laid 
down. 

Dislocation  Downward  Upon  the  Tuber- 
osity of  the  Ischium. — This  dislocation  is 
very  rare  because  of  the  ease  with  which 
it  may  be  converted  into  a  dorsal  or 
thyroid  dislocation.  The  thigh  is  sharply 
flexed  and  abducted.  Keduction  is  easy 
by  traction  in  flexion. 

Complications  of  Dislocations  of  the 
Hip. — Compound  dislocations  are  very 
rare. 

Injury  to  the  femoral  vessels  may  oc- 
cur in  forward  and  inward  dislocations. 

Fracture  of  the  neck  of  the  femur  is 
usually  caused  by  overzealous  attempts 
at  reduction.  Ankylosis  with  the  limb 
in  a  favorable  position  is  the  best  that 
can  be  hoped  for,  except  possibly  in  the 
young,  when  excision  of  the  head  of  the 
bone  may  give  some  useful  motion. 

Treatment  of  Old  Unreduced  Disloca- 
tions.— Of  the  operative  procedures,  re- 
diiction  by  arthrotomy  gives  a  long  list 
of  deaths  as  opposed  to  two  successes  (by 
Parkes),  while  excision  of  the  head,  or  of 
the  head,  neck,  and  trochanter,  and  sub- 
trochanteric osteotomy  have  frequently 
decreased  the  disability.  In  many  cases, 
however,  the  patients  do  reasonably  well 
without  operation,  and  these  persons 
need  expect  no  cure  from  the  knife. 

Dislocations  of  the  Knee. — These 
occur  rarely  and,  in  order  of  frequency, 
forward,  backward,  outward,  inward,  and 
by  rotation.  The  dislocation  is  fre- 
quently compound,  and  the  prognosis 
rendered  much  more  grave  by  a  compli- 
cating injury  to  either  of  the  popliteal 
nerves  or  to  the  popliteal  vessels.  Even 
if,  after  reduction,  pulsation  reappear  in 
the  arteries  of  the  foot,  gangrene  may 
supervene  from  thrombosis  caused  by 
laceration  of  the  inner  coats  of  the  artery. 

Forward  dislocation  may  be  complete, 


or,  more  commonly,  incomplete.  AMien 
complete,  the  tibia  may  be  displaced 
some  distance  upward  over  the  front  of 
the  condyles.  If  the  dislocation  is  com- 
pound, the  wound  is  posterior  and  trans- 
verse. The  cause  is  direct  violence  or 
hj^Dcrextension  of  the  knee.  Reduction 
is  easily  made  by  traction  and  pressure. 

Backward  dislocations  may  be  com- 
plete or  incomplete.  The  leg  is  usually 
either  extended  or  hyperextended,  and 
may  be  deviated  to  one  side.  The  patella 
may  be  dislocated  outward.  The  usual 
cause  is  direct  violence.  Eeduction  is 
effected  by  traction  and  pressure.  Even 
■nnthout  reduction  a  fairh'-useful  limb 
has  resulted  in  several  cases. 

Lateral  dislocations  are  outward  or  in- 
ward, complete  or  incomplete.  The  pa- 
tella is  usually  deviated  toward  the  side 
of  the  dislocation.  The  incomplete  form 
is  usually  caused  by  abduction  or  (in- 
ward) by  adduction.  Eeduction  by  trac- 
tion and  pressure.  Dislocation  by  rota- 
tion is  said  to  be  incomplete  when  one 
condyle  revolves  around  the  other,  com- 
plete when  both  revolve  around  a  central 
axis.  There  m-ay  be  additional  backward 
or  outward  displacement.  The  rotation 
is  said  to  be  outward  or  inward  accord- 
ing to  the  direction  in  which  the  toes 
turn.  Eeduction  is  easy.  All  knee-dis- 
locations should  be  kept  immobilized  for 
several  weeks  after  reduction. 

DlSLOCATIOX       OF      THE       SEMILUNAR 

Cartilages. — Either  cartilage  may  be 
detached  from  any  of  its  ligamentous 
attachments,  and  so  displaced  in  any  di- 
rection, or  it  may  be  lacerated. 

The  symptoms  are  those  of  any  loose 
body  in  the  joint,  sudden  painful  lock- 
ing, usually  after  some  given  movement. 
The  displacement  may  be  recognized  by 
palpation  along  the  articular  edge  of  the 
tibia.     The  cause  of  displacement  is  a 


586 


DISLOCATIONS.    PATELLA.    FIBULA. 


dislocation,  a  sprain,  excessive  rotation, 
or  flexion. 

Treatment. — The  locking  may  be  re- 
lieved by  forcible  manipulation  or  by 
pressure  upon  the  displaced  cartilage. 
Various  braces  have  been  devised  to  pre- 
vent recurrence,  either  by  opposing  the 
displacement  directly  or  by  preventing 
the  motion  which  occasions  the  displace- 
ment. These  methods  failing,  the  car- 
tilage may  be  removed  or  sutured  into 
place  through  an  exploratory  incision 
alongside  of  the  patella. 

Dislocations  of  the  Patella. — The 
patella  may  be  dislocated  outward  or  in- 
ward or  rotated  around  its  long  axis,  or 


Fig.  15. — Diagram  of  the  various  dislocations 
of  the  patella.     {Stimson.) 

the  two  forms  may  be  combined.  Dis- 
placement upward  or  downward  is  purely 
secondary  to  rupture  of  the  ligamentuin 
patella  or  the  quadriceps  tendon,  and 
need  not  be  here  considered. 

Outward  dislocation  is  complete  or  in- 
complete, and  accompanied  by  various 
degrees  of  rotation  (Fig.  15:  1,  2,  and  3). 
The  patella  is  readily  felt  in  its  new  posi- 
tion, though  it  may  be  difficult  to  deter- 
mine whether  the  outer  or  the  inner 
border  is  directed  forward.  Muscular  ac- 
tion or  direct  violence  are  the  causes  of 
the  dislocation,  and  hydrarthrosis  and 
ligamentous  weakness  are  predisposing 
causes.  The  fibrous  exjjansion  of  the 
vastus  internus  is  ruptured,  and  the  mus- 


cle itself  may  be  more  or  less  torn.  Re- 
duction is  made  by  direct  pressure  dur- 
ing extension  of  the  knee  and  flexion  of 
the  hips. 

Incomplete  dislocations  are  those  in 
which,  during  extension  or  flexion,  the 
patella  moves  outward  on  to  the  external 
condyle. 

Outiuard,  Edgewise,  or  Vertical  Dislo- 
cations {by  notation). — In  these  the  pa- 
tella is  moved  outward  and  its  inner  edge 
backward  into  the  intercondylar  groove; 
so  that  its  articular  surface  looks  outward 
and  more  or  less  forward,  or  completely 
forward  (Fig.  15:  4  to  7).  The  causes 
and  treatment  are  the  same  as  for  out- 
ward dislocations. 

Inward  dislocations  present  the  same 
features,  mutatis  mutandis,  as  the  out- 
ward, but  they  are  much  less  frequent. 

Habitual  dislocations  are  usually  the 
result  of  some  deformity,  such  as  genu 
valgum.  They  are  controlled  by  correct- 
ing the  original  deformity  or  by  appa- 
ratus, or  by  tightening  up  the  loose  lat- 
eral ligaments  (by  operation). 

Dislocation  of  the  Fibula.  —  The 
upper  end  may  be  dislocated  outward 
and  forward,  or  backward,  or  upward. 
These  dislocations  are  all  rare.  The  first 
form  seems  to  be  caused  by  muscular  ac- 
tion of  the  long  extension  of  the  foot; 
the  second  (in  more  than  half  the  cases) 
by  action  of  the  biceps,  and  tlie  third  by 
an  injury  resemliling  Pott's  fracture,  in 
which  the  fibula,  instead  of  being  broken, 
was  forced  upward. 

A  complicating  fracture  of  the  tibia 
may  exist.  Recurrence  is  likely,  al- 
though reposition  is  easy,  and  hence  im- 
mobilization should  be  maintained  for 
several  weeks. 

The  lower  end  may  be  dislocated  back- 
ward. This  is  quite  as  rare  as  the  dislo- 
cation outward  in  connection  with  Pott'a 
fracture  is  common. 


DISLOCATIONS. 


DYSEXTERY. 


5S7 


Dislocation  of  the  Ankle  (Tibio- 
Tarsal)  Backward.  —  By  extreme 
plantar  flexion  the  lateral  ligaments  are 
torn,  the  foot  slips  back,  and  the  astrag- 
alus is  caught  behind  the  tibia.  (Incom- 
plete dislocation  is  a  frequent  accompa- 
niment of  Pott's  fracture.)  The  malle- 
oli may  be  fractured.  The  lengthening 
of  the  heel  and  shortening  of  the  foot 
may  only  be  determined  sometimes  by 
careful  measurement. 

Fonvard. — Bare.  Caused  by  pressure 
on  the  heel  or  by  exaggerated  dorsal 
flexion. 

Inward. — Two  varieties.  In  the  one 
the  astragalus  is  pried  out  by  suppura- 
tion and  adduction,  and  the  foot  moved 
directly  inward  and  forward;  in  the 
other  (thought  to  be  secondary  to  a  back- 
ward dislocation)  the  foot  is  turned  over 
so  that  its  plantar  surface  faces  directly 
inward.    Keduction  is  easy. 

Outward. — Appears  always  to  be  asso- 
ciated with  Pott's  fracture. 

Subastragaloid  Dislocations. — 
The  other  bones  of  the  foot  may  be  dis- 
located from  the  astragalus  outward,  in- 
ward and  backward,  forward,  or  back- 
ward. The  first  two  are  the  most  com- 
mon. About  50  per  cent,  are  compound. 
About  50  per  cent,  of  attempted  reduc- 
tions have  succeeded.  Complicating 
fractures  are  not  infrequent.  Xotwith- 
standing  the  persistence  of  the  displace- 
ment, a  good  functional  result  may  be 
obtained  in  some  unreduced  cases.  Pri- 
mary and  secondary  excisions  of  the  as- 
tragalus and  amputations  give  various  re- 
sults. 

Dislocations  of  the  Astragalus. — 
The  varieties  are  forward,  backward,  out- 
ward and  forward,  inward  and  forward, 
and  by  rotation.  There  is  frequently 
■  more  or  less  rotation  in  connection  with 
the  other  displacements. 

Outward  and  Forward. — This  is  the 


most  frequent  form.  The  foot  is  ad- 
ducted  and  inverted  and  the  external 
malleolus  prominent.  The  astragalus 
rests  on  the  outer  cuneiform  and  cuboid 
bones,  or  even  on  the  fifth  metatarsal. 
Its  posterior  part  is  still  in  contact  with 
the  articular  surface  of  the  tibia.  Eeduc- 
tion  by  traction  on  the  foot  and  pressure 
on  the  astragalus  is  usually  easy,  unless 
the  bone  is  rotated. 

Inward  and  Forward. — The  foot  is  ab- 
ducted and  everted  and  the  astragalus 
lies  in  front  or  below  the  malleolus.  Re- 
duction may  be  prevented  if  the  tendon 
of  the  tibialis  anticus  embraces  the  neck 
of  the  dislocated  bone. 

Forward. — Very  rare.  The  cases  re- 
ported have  no  features  in  common. 

Backward. — There  may  be  lateral  dis- 
placement. In  about  50  per  cent,  of 
cases  the  bone  was  broken  at  the  neck 
and  only  the  posterior  fragment  dislo- 
cated. There  may  be  flexion  of  the  ter- 
minal phalanx  of  the  great  toe.  Reduc- 
tion was  effected  in  one-third  of  the 
simple  cases. 

Botatory.  —  Dislocation  by  rotation 
alone  may  take  place  about  the  vertical 
or  transverse  axis  (in  these  latter  there  is 
always  some  displacement  forward  and 
inward)  or  about  the  antero-posterior 
axis. 

Dislocations  of  the  Tarsus  and 
Metatarsus.  —  These  dislocations  re- 
semble those  of  the  carpus  and  meta- 
carpus {q.  v.).  The  external  cuneiform 
alone  has  not  been  dislocated  individu- 
ally. 

Lewis  A.  Stimson, 
Edward  L.  Ketes.  Jr., 

New  York. 

DYSENTERY.— Gr.,f^i..-,  difficult,  and 
fj'Tfpoj',    intestine. 

Definition. — An  acute  or  chronic  in- 
flammatory disease,  which  usually  affects 


588 


DYSEXTEKY.    VAKIETIES.    SYMPTOilS. 


the  large,  but  sometimes  the  small,  in- 
testine. The  structures  implicated  are 
the  solitary  and  more  rarely  the  agmi- 
nated  nodules,  and  the  general  enteric 
mucous  membrane.  Under  this  name 
are  described  several  diii'erent  forms  of 
intestinal  flux,  which  in  the  acute  stage 
are  characterized  by  fever  and  accom- 
panied by  tormina  and  tenesmus. 

Varieties. — Several  different  forms  of 
dysentery  are  distinguished  partly  upon 
anatomical  and  partly  upon  clinical  and 
etiological  grounds.  A  division  into 
endemic,  epidemic,  and  sporadic  has 
been  made.  It  is  probable  that  the 
endemic,  or  tropical,  form  owes  its  origin 
to  a  definite  species  of  micro-organism, 
the  amoeba  eoli.  The  epidemic  and  spo- 
radic varieties  are  of  uncertain  etiology. 
For  clinical  purposes  a  separation  into 
catarrhal,  diphtheritic,  and  amoebic  dys- 
entery may  be  made. 

General  Symptoms. — The  first  symp- 
toms of  dysenterj'  usually  set  in  without 
prodromata.  A  natural  movement  is  fol- 
lowed by  several  diarrhoeic  stools  with- 
out either  pain  or  tenesmus.  The  size 
of  the  movements  gradually  diminish, 
they  become  admi.xed  with  mucus  and 
blood,  and  are  accompanied  by  colic,  bor- 
borygmi,  and  tenesmus.  It  sometimes 
happens  that  the  disease  is  ushered  in 
with  bloody  and  mucous  stools,  pain,  and 
tenesmus.  In  light  grades  constitu- 
tional symptoms  are  scarcely  present;  in 
severe  ones  the  disease  begins  with  chill, 
fever,  loss  of  appetite,  nausea,  and  faint- 
ness.  The  evacuations  remain  diarrhojic 
and  contain  only  mucus,  when  we  have 
to  deal  with  a  mild  catarrhal  inflamma- 
tion, or  they  become  admixed  witli  blood, 
pure  bloody,  pseudomemliranous,  or  pur- 
ulent, indicating  more  severe  lesions. 

The  several  kinds  of  dysentery  present 
difTerent  stages.  The  epidemic  and  spo- 
radic forms  may  be  separated  into  ca- 


tarrhal, diphtheritic,  and  ulcerative 
stages.  The  endemic  form,  and  espe- 
cially the  amcebic  variety,  appears  in  the 
ulcerative  stage  almost  e.xclusively.  The 
last  also  shows  a  greater  tendency  to  be- 
come chronic  and  to  relapse. 

Special  Symptoms. — (A)  Calarrhal 
Dysentery. — In  this  form  prodromata, 
except  dyspepsia  and  slight  abdominal 
pains,  are  rare.  Diarrhoea  is  the  most 
constant  initial  symptom  and  at  first  it 
is  not  painful.  The  characteristic  feat- 
ures of  the  disease — colicky  and  griping 
abdominal  pain,  frequent  stools,  and 
straining — are  usually  developed  within 
the  first  thirty-six  hours.  The  consti- 
tutional symptoms  are,  as  a  rule,  insig- 
nificant; tlie  temperature  is  little  ele- 
vated; the  pulse  rarely  exceeds  100;  the 
tongue  is,  at  first,  furred  and  moist,  but 
later  becomes  red  and  glazed;  nausea 
and  vomiting  may  be  present.  The  ab- 
domen may  be  flat  and  hard  and  the 
thirst  excessive.  There  is  constant  de- 
sire to  go  to  stool.  The  stools  present 
the  following  characters:  During  the 
first  twenty-four  or  forty-eight  hours 
they  consist  of  more  or  less  clear  mucus 
and  blood,  with  small,  scybalous  masses. 
Under  strict  regimen,  as  early  as  the 
second  day,  they  may  be  composed  en- 
tirely of  mucus  and  blood,  and  their  con- 
sistence may  be  so  viscid  that  the  bed- 
pan may  be  turned  upside  down  in  many 
cases  without  spilling  the  contents.  The 
number  of  stools  in  twenty-four  hours 
varies  from  15  to  200.  Tliis  condition 
may  persist  for  one  or  two  weeks,  the 
mucus  becoming  gradually  more  opaque, 
of  a  grayish-white  color,  the  blood  pro- 
gressively diminishing  in  quantity,  and 
a  little  gray,  green,  or  brown  pultaceous 
detritus,  or  fluid  ftecal  matter,  appear- 
ing in  the  stools.  As  the  disease  sub- 
sides, fffical  matter  again  makes  its  ap- 
pearance,   increasing   in    amount   until 


DYSENTERY.    SYMPTOMS. 


589 


fully-formed  fecces  are  passed,  showing 
neither  mucus  nor  blood.  In  the  more 
prolonged  cases  wholly  pultaceous,  yel- 
low-brown or  greenish  (spinach)  evacua- 
tions may  intervene  between  the  bloody, 
mucoid  stools  and  the  passage  of  formed 
faeces.  Microscopical  examination  of  the 
stools  shows  in  the  first  bloody,  glairy 
discharges  a  predominance  of  red  blood- 
corpuscles.  AVith  these  are  associated 
leucocytes  and  cylindrical  epithelial  cells 
in  small  numbers,  and  constantly  large 
round  or  oval  epithelioid  cells.  In  later 
stages  the  stools  contain  fewer  red  cor- 
puscles and  more  leucocytes;  in  the  pul- 
taceous material  cellular  elements  are 
scarce.  Bacteria  are  more  abundant  in 
the  later  stages;  amcebje  are  absent;  oc- 
casionally the  Cercomonas  inteslinalis  is 
seen  in  large  numbers.  The  duration  of 
the  disease  is  variable;  according  to 
Flint,  the  milder  cases  terminate  in 
about  eight  days;  severe  ones  may  last 
as  long  as  a  month.  The  disease  rarely 
becomes  chronic. 

Amcebic  dysentery  lias  so  rarely  been 
described  in  children  that  the  diagnosis 
is  probably  never  entertained  by  the 
practitioner.  Within  a  short  space  of 
time  five  cases  were  identified  and  suc- 
cessfully treated  by  the  author  at  the 
Johns  Hopkins  Hospital.  The  patients 
ranged  in  age  from  2  to  5  years, 
and  ilhistrated  a  moderately  severe  type 
of  the  disease,  with  the  exception  of 
one  child  who  was  very  seriously  sick. 
The  clinical  picture  in  these  cases  was 
very  indefinite.  The  appetite  and  gen- 
eral health  were  good,  fever  and  ac- 
celeration of  the  pulse  were  hardly  notice- 
able, and  the  blood-examination  showed 
only  a  very  moderate  anncmia  of  the  sec- 
ondary type.  Stools  varied  from  two 
to  six  in  twenty-four  hours,  were  rarely 
associated  with  pain,  and  presented 
nothing  characteristic  to  the  eye.  They 
were  of  every  degree  of  consistence,  and 
might,  or  might  not,  show  admixture  of 
blood.  The  odor  was  always  most  offen- 
sive.   Microscopically,  three  very  typical 


structures    are    to    be    found,    namely: 
live   amoebiE   containing   red   blood-cells, 
Charcot-Le3-den  crystals,  and  numerous 
eosinophile  cells.    The  presence  of  either 
of  tlie  latter  elements  should  make  the 
observer  extremely  suspicious  of  amoebic 
dysentery,   as   they   occur   in   no   other 
condition    except    helminthiasis,    which 
can  easily  be  excluded.    The  presence  of 
the  amoeba  is,  of  course,  final.    S.  Am- 
berg   (Bull.  Johns  Hopkins  Hosp.,  Dec, 
1901). 
(B)  Diphiherilic  Dysentery. — The  pri- 
mary variety  presents  somewhat  differ- 
ent symptoms,  depending  upon  the  stage 
— whether  acute  or  chronic — of  the  dis- 
ease.   In  the  acute  stage  the  symptoms 
often  from  the  outset  are  severe.    There 
may  be  high  fever,  great  prostration,  ab- 
dominal pain,  and  frequent  discharges, 
with  tormina  and  tenesmus.     The  grip- 
ing pain   and   straining  are  the  chief 
sources  of  sufEering.    Delirium  may  set 
in  early,  and  the  clinical  features  resem- 
ble severe  typhoid.     Osier  states  that 
he  has  known  this  mistake  to  be  made 
on  more  than  one  occasion.    The  pulse, 
in  the  majority  of  cases,  is  but  little,  and 
sometimes  not  at  all,  accelerated.    Fever, 
except  in  the  severe  cases,  is  not  a  prom- 
inent feature.     Flint  states  that  great 
frequency  of  the  pulse  denotes  gravity 
and  danger,  but  that  the  converse  does 
not  always  hold  good.     The  discharges 
are  frequent  and  diarrhoeal  in  character; 
blood  and  mucus  may  be  found  early, 
and  sloughs  may  make  their  appearance. 
The  presence  of  pseudomembrancs  and 
of   necrotic   portions   of   the   intestinal 
coats  is  characteristic  of  the  diphtheritic 
form  of  inflammation.     The  other  in- 
gredients are  common  to  both  the  ca- 
tarrhal and  the  diphtheritic  varieties  of 
inflammation.     Upon   microscopical  ex- 
amination   the    cellular    elements    are 
found  to  be  relatively  few  in  numbers, 
those    most    constantly    present    being 
cylindrical  epithelial  cells,  showing  more 


590 


DYSENTERY.    SYMPTOMS. 


or  less  fatty  degeneration.  Eed  blood- 
corpuscles  and  leucocytes  are  observed, 
especially  where  much  blood  and  mucus 
are  admixed,  and  large  numbers  of 
leucoe3i;es  in  the  purulent  discharges. 
Fibrin  also  occurs,  and  bacteria  appear 
in  great  numbers.  When  improvement 
begins  feculent  matter  appear  in  the 
stools.  The  duration  of  the  disease 
from  the  date  of  attack  to  convalescence 
varies  from  four  to  twenty-one  days. 
When  death  takes  place  it  usually  re- 
sults from  asthenia.  The  pulse  becomes 
weaker  and  accelerated,  the  tongue  dry, 
the  face  pinched,  the  skin  cool  and  cov- 
ered ^s-ith  sweat,  and  the  patient  sinks 
into  a  drowsy  condition.  Consciousness 
may  be  retained  until  the  end. 

(C)  Chronic  Dysentery. — This  condi- 
tion usually  succeeds  an  acute  attack. 
Clinically  the  chronic  forms  of  diph- 
theritic are  not  sharply  marked  off  from 
those  of  amoebic  dysentery.  The  latter 
disease  may  be  subacute  from  the  outset 
and  fail  to  present  an  acute  period.  The 
lesions  in  the  intestine  will  depend  upon 
the  origin:  if  amoebic,  then  ulceration 
with  little  tendency  to  healing  is  the 
rule;  if  diphtheritic,  then  pigmented 
cicatrices  or  these  together  with  imper- 
fectly-healed ulcers  are  met  with.  The 
intestinal  walls  are  thickened  and  the 
sigmoid  fle-xure  may  be  palpated  as  a 
hard,  resistant  tube.  The  disease  pre- 
sents protean  symptoms  and  cannot 
always  be  sharply  separated  from  chronic 
diarrhoea.  Its  course  may  extend  over 
months  and  even  years.  Many  of  the 
characteristics  of  the  acute  disease  are 
wanting.  The  composition  of  the  stools 
is  variable;  blood,  necrotic  tissue,  and 
pseudomemljranes  are  rarely  found. 
There  are  periods  of  improvement  and 
exacerbation;  the  patient  loses  weight 
and  strength,  becomes  emaciated,  suf- 
fers  from  periods  of  psychical  depres- 


sion, and  may  become  bedridden.  The 
degree  of  emaciation  may  be  extreme, 
and  a  severe  secondary  anamia  some- 
times develops.  The  evacuations — 
which  vary  from  five  to  twelve  or  more 
in  the  twenty-four  hours — take  place 
usually  without  tenesmus,  and  with  only 
slight  colicky  pains.  They  are  lluid,  of 
greenish-yellow  or  brownish-black  color, 
now  and  then  admixed  with  blood  and 
mucus.  Sometimes  the  stools  are  puru- 
lent. Indiscretions  in  diet  are  followed 
by  an  increase  in  the  colicky  pains. 

(D)  AmceMc  Dysentery. — The  symp- 
toms presented  are  very  variable.  What 
characterizes  the  disease  are  an  "irregu- 
lar course  marked  by  periods  of  inter- 
mission and  of  exacerbation  of  the  diar- 
rhoea, a  tendency  to  chronicitj',  and  the 
frequent  occurrence  of  abscess  of  the 
liver"  (Lafleur).  For  clinical  purposes 
Lafleur  groups  the  cases  under  (a)  grave 
or  gangrenous  forms;  (b)  dysentery  of 
moderate  intensity  (showing  periods  of 
intermission  and  of  exacerbation);  (c) 
chronic  forms.  Ivartulis  recognizes  ca- 
tarrhal and  ulcerative  stages  in  the 
diseases.  The  catarrhal  stage,  in  contra- 
distinction to  epidemic  dysentery,  is 
relatively  of  infrequent  occurrence. 
This  stage  tends  to  pass  into  the  more 
severe  or  ulcerative  form.  In  the  ca- 
tarrhal stage  the  dejections  are  yellow, 
bile-stained,  and  of  mushy  or  lluid  con- 
sistence. When  the  stools  arc  small, 
then  mucus,  which  may  be  blood-stained, 
appears.  As  the  intensity  of  the  symp- 
toms increases  clumps  of  mucus  and 
blood  are  more  abundant;  still  later  the 
stools  present  a  beef-water  appearance, 
in  which  clear  clumps,  resembling  frog- 
spawn,  —  altered  starch-grains,  —  float. 
With  the  advance  of  the  ulceration  they 
become  more  copious,  watery,  and  less 
homogeneous;  there  is  less  blood  and  a 
great  deal  of  shreddy  material  appears 


DYSEXTEKY.    bYilPTOMS. 


591 


admixed  with  the  mucus.  Fragments  of 
necrotic  tissue  from  the  bases  of  the 
ulcers, — small,  grayish-yellow  masses, — 
which  always  contain  amoebje,  are  pres- 
ent. When  there  is  great  and  rapid 
sloughing,  then  the  stools  are  greenish, 
grayish,  or  reddish  brown  and  are  still 
more  variegated  in  appearance.  In  con- 
sistence they  are  watery  or  pultaceous 
and  in  odor  penetrating  and  highly 
offensive.  In  the  chronic  form  the  stools 
are  homogeneous,  watery,  or  gruel-like; 
they  contain  few  or  many  flakes  of  clear 
mucus,  but  seldom  any  blood  or  necrotic 
fragments  of  tissue. 

The  microscopical  examination  of  the 
bloody,  mucoid  stools  shows  red  blood- 
corpuscles,  leucocytes,  oval  and  round 
epithelioid  cells,  cylindrical  epithelial 
cells  in  small  numbers,  crystals  of  am- 
monia-magnesian  and  earthy  phosphates, 
Charcot's  crystals,  occasionally  blood-pig- 
ment, and  amoebae.  At  later  stages  the 
cellular  elements  are  less  numerous,  the 
amorphous  detritus  increased,  and  elastic 
tissue  may  be  met  with.  In  the  liquid 
stools  of  the  chronic  form  few  formed 
elements  except  amoebae  occur.  With 
each  exacerbation  there  is  an  increase  of 
the  cellular  elements. 

In  the  grave  form  the  stools  are,  at 
first,  numerous,  twenty  to  thirty  in 
twenty-four  hours;  as  the  disease  ad- 
vances they  diminish  to  a  dozen  or  less, 
and  in  fatal  cases,  toward  the  end  may 
not  exceed  three  or  four. 

Abdominal  pain  and  tenesmus  are  fre- 
quently present  at  the  outset,  especially 
in  severe  cases,  but  may  be  entirely  ab- 
sent. Vomiting  and  nausea  are  only  oc- 
casionally observed.  Fever  is  an  incon- 
stant symptom  and  ranges  from  99°  to 
101°  or  102°.  With  the  development 
of  complications  (liver-abscess,  etc.)  it 
is  more  persistent  and  tends  to  become 
more  regularly  intermittent.    The  pulse, 


in  most  instances,  follows  the  variations 
in  temperature.  In  the  fatal  stage  of 
gangrenous  dysentery  the  pulse  becomes 
rapid, — 120  to  140  or  more — thready, 
and  compressible;  and  at  the  same  time 
the  temperature  tends  to  fall  below  nor- 
mal. Anaemia,  of  greater  or  less  severity, 
appears  in  all  cases;  albuminuria  of 
slight  grade  is  of  frequent  occurrence, 
and  hyaline  casts  are  sometimes  found 
in  the  urine. 

The  examination  of  the  stools  for  the 
amoebae  coli  is  very  important  and  should 
never  be  omitted.  Sometimes  a  single 
examination  sutfices  to  demonstrate  ac- 
tively-moving amoebae.  In  chronic  cases, 
however,  repeated  examinations  may  be 
required.  In  cases  of  liver-  and  of  lung- 
abscess  the  diagnosis  of  the  intestinal 
disorder  may  be  established  by  finding 
the  amoebae  in  the  aspirated  contents  of 
the  former  or  in  the  sputa  derived  from 
the  latter.  In  making  the  examinations 
for  amoeba;  it  is  advised  that  the  stools 
be  passed  into  a  warm  bed-pan  and  kept 
at  the  body-temperature  during  the  ob- 
servation. The  examination  should  be 
made  at  once  or  very  soon  after  collect- 
ing the  faeces,  and  the  most  favorable 
parts  should  be  chosen  for  the  examina- 
tion. A  warm  stage  greatly  facilitates 
the  examination. 

Special  S3'mptoms  referable  to  com- 
plications are  apt  to  arise.  Those  most 
commonly  met  with  are  in  connection 
with  liver-  and  lung-abscesses,  peritonitis 
with  or  without  perforation  of  the  iu- 
testine,  and  intestinal  haemorrhage. 

The  duration  of  the  disease  in  uncom- 
plicated cases  varies  from  six  to  twelve 
weeks.  Recovery  is  tedious,  relapses  are 
frequent,  and  there  is  a  constant  tend- 
ency to  chronicity.  In  uncomplicated 
cases  recovery  may  be  expected  when  the 
freces  become  formed  and  amccboe  disap- 
pear from  the  stools. 


592 


DYSEXTERY.     COMPLICAXIOXS.     DIAGNOSIS.     ETIOLOGY'. 


Complications.  —  A  local  peritonitis 
may  arise  by  extension,  or  a  diffuse  in- 
flammation, which  is  usually  fatal,  may 
foUow  perforation.  A  local  inflamma- 
tion about  the  c^^cum  gives  rise  to  peri- 
tj'phlitis;  if  about  the  rectum,  periproc- 
titis. The  regional  lymphatic  glands 
may  be  swelled  and  hypertemic,  and 
rarely  do  they  undergo  suppuration.  A 
serious  complication  is  pylephlebitis  af- 
fecting the  veins  of  the  intestine  and 
mesentery,  owing  to  the  danger  of  em- 
bolic abscess  of  the  liver.  The  abscesses, 
in  these  cases,  may  be  single  or  multiple. 
Intestinal  stricture  is  a  rare  sequence; 
amyloid  degeneration  of  the  viscera  and 
dropsical  conditions  are  uncommon  con- 
sequences of  chronic  dysentery.  The  dis- 
eases associated  with  dysentery  which 
have  been  noted  are  rheumatic  swelling 
of  the  joints,  malaria,  typhoid  fever, 
pleurisy,  pericarditis,  and  endocarditis. 

Case  of  severe  dysentery  complicated 
with  infectious  pseudorheumatism,  ar- 
thritis, with  sero-purulent  effusion  of  the 
left  knee,  necessitating  arthrotomy  and 
drainage  of  the  articular  cul-de-sacs.  J. 
Brault  (Lyon  MCd.,  Jan.  27,  '95). 

The  sequelae  of  the  disease  as  met 
with  in  the  Philippine  Islands  are  the 
following:  Chronieity;  chronic  gastri- 
tis and  indigestion ;  obstinate  constipa- 
tion; paralysis  (partial)  of  the  large 
intestines,  due  either  to  obliteration  of 
the  glands  and  lack  of  secretion  or  to 
lack  of  innervation  and  blood-supply; 
aneemia  from  lack  of  assimilation  of 
food;  association  of  malarial  fever; 
typhoid  fever;  neuritis;  atrophic  cir- 
rhosis of  the  liver;  chronic  parenchy- 
matous nephritis;  abscess  of  the  liver; 
metastatic  abscesses  of  other  organs,  as 
of  the  lungs  and  kidneys;  inanition; 
toxaemia;  dilatation  of  the  stomach  and 
intestines.  S.  M.  Long  (N.  Y.  Med. 
Jour.,  Mar.  30,  1001). 

Diagpiosig.  —  The  diagnosis  of  dysen- 
tery usually  involves  no  great  difficulty. 


The  characteristic  evacuations  are  path- 
ognomonic. The  diseases  from  which  it 
is  to  be  discriminated  are  local  affections 
of  the  rectum,  such  as  syphilis  and  epi- 
thelioma, which  may  produce  tenesmus 
with  the  passage  of  mucoid  and  bloody 
stools,  and  hemorrhoids,  and  a  discharg- 
ing intestinal  abscess,  in  which  certain 
of  the  symptoms  are  simulated. 

Etiology  and  Epidemiology. — Dysen- 
tery is  one  of  the  four  great  epidemic  dis- 
eases of  the  world.  In  the  tropics  it 
destroys  more  lives  than  cholera,  and  it 
has  been  more  fatal  to  armies  than  pow- 
der and  shot  (Osier).  From  the  ac- 
counts furnished  by  history  and  the 
numerous  ones  supplied  by  physicians  in 
the  last  three  centuries  bearing  upon  its 
epidemiologj',  it  may  be  concluded  that, 
just  at  present,  dysentery  has  at  all  times 
had  the  widest  distribution  over  the 
globe  and  that  no  considerable  part  has 
been  exempted  from  a  visitation.  To 
quote  Ayres,  "of  dysentery  it  may  be  said 
that,  where  man  is  found,  there  will  some 
of  its  forms  appear." 

The  present  geographical  distribution 
of  dysenteric  and  diaTrha3al  diseases  ia 
compared  by  Ilirsch  with  that  of  the 
malarial  diseases,  with  which,  in  respect 
to  the  manner  of  their  endemic  preva- 
lence, the  frequency  of  their  epidemic 
outbreaks,  and  the  varying  severity  of 
their  type,  they  are  in  correspondence. 

Like  the  malarial  diseases,  they  reach 
the  maximum  of  diffusion  and  of  inten- 
sity, and  more  especially  their  greatest 
severity  as  an  endemic,  in  equatorial  lati- 
tudes; in  subtropical  countries  there  be- 
gins to  be  noticed  a  decrease  in  the  ex- 
tent and  seriousness  of  endemic  and  epi- 
demic incidence;  while  in  still  higher 
latitudes  they  almost  disappear  as  en- 
domic  diseases  and  show  themselves 
merely  now  and  then  in  epidemics  over 
an  area  at  one  time  large  and  another 


DYSENTERY.    ETIOLOGY. 


593 


time  small.  In  one  point  they  differ 
from  malarial  diseases,  namely:  that 
they  attain  to  higher  latitudes  of  the 
cold  zone,  appearing  as  epidemics  in  re- 
gions that  are  quite  free  from  malaria. 

The  endemic  form  of  dysentery  has  al- 
ways existed  in  Africa  and  India,  but  the 
place  of  its  natural  home  is  not  known. 
Its  present  distribution  includes  Africa 
in  its  entire  extent,  except  for  a  few  lo- 
calities. Both  natives  and  Europeans  are 
affected.  In  South  Africa  it  prevails  se- 
verely in  Bechuanaland,  Natal,  and  the 
Transvaal.  In  the  north  it  appears  in 
Egypt,  especially  along  the  coast  and  the 
Nile  delta.  In  Asia  it  prevails  to  a  great 
extent  along  the  Arabian  coast  of  the 
Eed  Sea  as  well  as  of  the  Gulf  of  Aden 
and  the  Persian  Gulf.  It  exists  in  Syria, 
Asia  Minor,  and  extends  into  Mesopo- 
tamia and  Persia.  Endemic  dysentery  is 
widely  disseminated  in  India  and  the 
Indian  Archipelago  and  exists  in  China. 
In  Japan  it  assumes  a  milder  form,  while 
the  epidemic  variety  is  very  destructive. 
The  disease  prevails  in  the  tropical  and 
subtropical  parts  of  South  America,  but 
it  fails  to  reach  the  wide  diffusion  which 
it  presents  in  Africa  and  India.  In 
Guiana  it  is  found  in  the  mountainous 
regions  and  in  the  tropical  parts  of  Brazil 
in  a  severer  form.  In  Valparaiso  and 
La  Serena  in  Chile  the  disease  has  a 
home.  Foci  appear  in  Paraguay  and  in 
the  tropical  provinces  of  Argentine  Re- 
public. In  Peru  it  occurs  along  the 
marshy  districts  of  the  Amazon  and  in 
some  of  the  mountainous  regions,  being 
endemic  in  the  city  of  Cero  de  Pasco  at 
an  elevation  of  13,000  feet.  Venezuela 
does  not  escape;  in  Uruguay  it  is  almost 
unknown.  In  Central  America  the  dis- 
ease prevails  in  Panama,  Costa  Rica, 
Nicaragua,  Salvador,  Honduras,  and 
Gautemala.  It  is  diffused  over  Mexico 
and  appears  at  elevations  of  6000  feet. 

2- 


It  assumes  the  severest  forms  in  the  West 
Indies,  especially  in  Cuba  and  Hayti,  and 
prevails  to  a  greater  or  less  extent  in 
Guadeloupe,  Martinique,  and  Barbadoes. 
In  Europe  endemic  dysentery  occurs  over 
limited  areas  only,  and  is  present  in  the 
more  southernly-placed  countries.  Thus 
it  is  known  in  Greece,  but  is  endemic  in 
the  Ionian  Islands  and  the  Cyclades.  In 
Turkey  it  is  common,  in  Bulgaria  and 
Roumania,  along  the  Donau,  also,  while 
the  southern  provinces  of  Italy  and  Sic- 
ily are  the  most  severely  affected  regions 
in  Europe.  France,  Switzerland,  Bel- 
gium, the  Netherlands,  and  Great  Britain 
are  free  from  endemic  dysentery.  In 
Germany  there  are  no  definite  foci  of 
occurrence,  but  a  number  of  cases  of  the 
disease  have  been  observed  at  Weimar 
and  Kiel.  The  same  facts  are  true  of 
Austria,  which,  in  general,  has  escaped, 
although  cases  have  been  reported  from 
Prague,  Graz,  and  Vienna. 

The  distribution  upon  this  continent, 
and  especially  in  the  United  States,  of 
the  endemic  form  of  dysentery  is,  at 
present,  difficult  to  estimate.  If  we  ac- 
cept this  variety  as  synonymous  with 
tropical  and  amcebic  dysentery,  a  much 
closer  study  of  the  disease  than  yet  made 
will  be  necessary  in  defining  the  limits 
of  its  prevalence.  Cases  have  been  re- 
ported from  Maryland,  Massachusetts, 
Pennsylvania,  Texas,  Ohio,  Alabama, 
and  Georgia.  But  it  seems  probable  that 
many  of  the  so-called  sporadic  cases  oc- 
curring in  this  country,  and,  perhaps,  not 
a  few  of  the  epidemic  ones,  may  be  shown 
to  be  of  this  kind.  With  the  exception 
of  the  investigations  of  the  disease  car- 
ried out  in  Egypt,  Germany,  Austria,  and 
Italy,  the  American  cases  above  referred 
to  have  been  the  most  thoroughly 
studied. 

The  epidemic  form  of  dysentery  is 
oftenest  confined  to  a  single  locality,  a 


594 


DYSENTERY.    ETIOLOGY. 


\'illage  or  a  towTi,  witli  no  extension  to 
the  country  aroimd.  Instances  are  not 
rare  in  which  the  epidemic  attacks  a 
single  detached  establishment,  such  as  a 
prison,  a  hospital,  a  poor-house,  a  sol- 
diers' barracks,  or,  under  certain  circum- 
stances, a  sliip,  while  there  are  no  cases 
of  dysentery  outside  these,  or  merely  oc- 
casional cases  (Hirsch).  It  happens 
much  more  rarely  that  the  disease 
achieves  a  greater  diffusion,  and  most 
rarely  do  pandemics  arise.  Mention  has 
already  been  made  of  the  prevalence  of 
dysentery  as  an  epidemic  disease,  espe- 
cially in  earlier  historical  times.  Great 
epidemics  have  not  appeared  in  recent 
years.  The  countries  which  have  been 
most  severely  visited  are  Italy,  France. 
Ireland,  Denmark,  and  Norway  and  Swe- 
den. In  the  United  States,  dysentery  in 
an  epidemic  form,  except  during  the  "War 
of  the  Eebellion,  has  not  in  late  years 
reached  serious  proportions.  According 
to  Woodward,  it  prevails  annually  among 
the  civil  populations  in  all  parts  of  the 
United  States.  It  occurs  both  in  the 
form  of  sparodic  cases  and  of  small  local 
epidemics  which  fasten  upon  different 
districts  in  different  years. 

Sporadic  dysentery,  which  is  distin- 
guishable both  from  the  endemic  and  the 
epidemic  forms,  is  of  very  uncertain  oc- 
currence. This  variety  of  dysentery  is 
attributed  by  Kartulis  to  the  action  of 
mechanical  and  chemical  irritants  upon 
the  intestine,  and  arises  as  a  secondary 
condition  in  the  course  of  other  diseases, 
Buch  as  acute,  infectious,  and  chronic  dis- 
eases of  the  heart,  kidneys,  and  liver. 
By  most  writers  the  occasional  cases  of 
dysentery  met  with  in  all  countries  are 
included  under  this  term. 

Various  telluric  conditions  have,  from 
time  to  time,  been  supposed  to  influence 
the  prevalence  of  dysentery.  Of  late 
years  the  search  has  been  made  for  micro- 


organisms to  the  action  of  which  the 
disease  might  be  attributed.  With  what 
success  this  line  of  investigation  has  been 
piirsued  will  be  stated  in  other  parts  of 
this  article.  It  is  a  well-known  fact,  and 
one  borne  out  by  the  best  statistics,  that 
both  the  epidemic  and  the  endemic  forms 
prevail  especially  during  the  hot  seasons. 
Great  diurnal  variations  of  temperature 
— warm  days  and  cold  nights — have  been 
supposed  to  predispose  to  the  develop- 
ment of  the  disease,  but  in  Egypt  the 
facts  observed  are  in  direct  opposition  to 
this  view.  The  degree  of  atmospheric 
moisture  seems  without  influence:  Hirsch 
states  that,  of  12  G  epidemics  of  dysen- 
tery, 65  occurred  during  moist  weather 
and  61  during  continued  drought.  The 
elevation  and  configuration  of  the  sur- 
face seem  also  without  particular  signifi- 
cance, although  low-lying  and  marshy 
localities  are  more  subject  to  visitations 
than  high  and  dry  ones. 

There  is  good  reason  to  believe  that 
the  dissemination  of  the  virus  of  dysen- 
tery takes  place,  in  large  part,  through 
the  water.  And,  although  the  same  con- 
clusive evidence  of  water-infection  has 
not  been  brought  for  this  disease  as  has 
been  brought  for  cholera,  yet  there  are 
many  convincing  observations  at  hand 
which  bear  out  this  belief.  Numerous 
ovitbreaks  both  of  the  endemic  and  epi- 
demic varieties,  among  troops  and  in- 
habitants of  towns,  have  been  traced  di- 
rectly to  contaminated  drinking-water; 
and  the  replacement  of  the  polluted  by 
a  wholesome  supply  has  been  quickly  fol- 
lowed by  a  cessation  in  the  spread  of  the 
disease.  Observations  which  indicated  a 
more  contagious  character,  a  transmis- 
sion from  person  to  person,  arc  not  want- 
ing. But  whether,  in  these  instances, 
the  virus  may  not  have  been  carried  by 
water,  wasb-linoii,  or  food  is  not  corfainly 
knoAvn. 


DYSENTERY.    ETIOLOGY. 


595 


The  demonstration  of  parasitic  organ- 
isms bearing  an  etiological  relation  to 
dysentery  has  been  done  certainly  only 
for  the  endemic  variety.  Several  differ- 
ent bacterial  organisms  have  been  de- 
scribed in  association  with  the  epidemic 
dysentery.  The  proof  of  their  essential 
causal  relationship  with  the  disease  has 
yet  to  be  brought.  The  several  micro- 
organisms will  be  considered  with  their 
respective  diseases. 

Amcebic  Dysentery. — This  affection 
is  also  known  as  endemic  and  tropical 
dysentery,  and  as  amcebic  enteritis.  It  is 
characterized  clinically  by  irregular  diar- 
rhoea, a  variable  course  often  marked  by 
periods  of  intermission  and  exacerbation, 
a  special  tendency  to  chronicity,  and  the 
development  of  liver-abscess,  and  ana- 
tomically by  ulceration  and  thickening 
of  the  large  intestine. 

Morbid  Anatomy  and  Etiology. — This 
form  of  dysentery  has  been  known  ana- 
tomically for  more  than  a  century:  since 
the  writings  of  John  Hunter,  who  ob- 
served the  disease  in  Jamaica.  The  prin- 
cipal contributions  upon  its  pathology 
has  been  made  by  Councilman  and  La- 
fleur,Krusc  and  Pasquale,Kartulis,  How- 
ard and  Hoover,  Fle.xner  and  Harris. 

The  lesions  in  the  intestine  are  of  two 
kinds:  (1)  a  general  catarrhal  inflamma- 
tion of  the  large  gut,  which  does  not  dif- 
fer from  catarrhal  colitis  due  to  other 
causes;  (2)  the  specific  focal  lesions  (ul- 
ceration) caused  by  the  presence  in  the 
tissues  of  the  amoeba  coli.  The  specific 
lesions  are  located  oftenest  in  the  sigmoid 
flexure,  somewhat  less  often  in  the 
CEPCum  and  ascending  colon,  and  more 
rarely  in  the  descending  and  transverse 
colon  and  rectum  (Kartulis).  The  verm- 
iform appendi.x  may  be  the  scat  of  ulcera- 
tion; most  rarely  does  the  dysenteric 
process  pass  beyond  the  ileo-ca?cal  valve 
and  attack  the  lower  end  of  the  ileum. 


The  amoebae  are  present  upon  the  sur- 
face of  the  intestine  and  in  the  interior 
of  the  crypts,  where  by  continued  irri- 
tation they  bring  about  destruction  of 
the  epithelium;  they  may  then  be  ob- 
served to  penetrate  through  the  inter- 
glandular  tissue  into  the  depth.  They 
set  up  an  active  inflammation  in  the 
mucosa,  shown  by  the  hyperemia,  ec- 
chymosis,  and  swelling  of  the  glandular 
epithelial  cells.  The  farther  extension 
of  the  amceba  takes  place  after  the  par- 
tial destruction  of  the  muscularis  mu- 
cosae. The  organisms  now  reach  the 
submucosa,  where  the  principal  damage 
is  inflicted.  The  number  of  amcebae  in 
the  submucosa  is  considerable;  their 
presence  excites  a  reactive  inflammation, 
and  soon  a  solution  of  the  tissues  in 
which  lie.  Thus  a  cavity  is  formed 
which,  sooner  or  later,  is  followed  by  ne- 
crosis and  removal  of  the  overlying  mu- 
cous membrane.  '^Ticn  this  happens,  an 
ulcer  is  the  result.  The  lymphoid  folli- 
cles are  not  especially  attacked;  they 
simply  share  the  fate  of  the  surrounding 
tissue.  The  muscular  coat  offers  some 
resistance;  it  is  not  generally  destroyed, 
but  the  amoebae  pass  through  it  in  cer- 
tain places,  enter  the  intermuscular  tis- 
sue, and  there  repeat  the  part  they  play 
in  the  submucous  tissue;  the  structures 
overlying  the  infiltration,  deprived  of 
their  nourisliment,  undergo  necrosis. 
The  ulcers  increase  by  this  continual 
process  of  undermining;  but  the  typical 
course  and  appearance  of  the  ulcer  may 
be  completely  changed  through  the  ac- 
tion of  the  bacteria  in  the  intestinal 
canal. 

The  ulcers  are,  for  the  most  part,  un- 
dermined. Often  the  defect  in  the  mu- 
cous membrane  is  small  and  altogether 
inconsiderable,  while  the  cavity  in  the 
submucosa  and  deeper  tissues  is  large, 
and  sinuous  tracts,  sometimes  connecting 


596 


DYSENTERY.    ETIOLOG'X. 


several  ulcers,  are  met  with.  Again,  sim- 
ple ulcers,  with  little  or  no  undermining 
of  the  mucous  membrane  and  limited  to 
the  submucosa,  exist.  Both  forms  may 
be  associated.  More  rarely  still,  large 
sloughs,  which  may  consist  of  the  mu- 
cous or  muscular  coats,  are  encountered. 
The  part  of  the  intestine  involved  be- 
comes much  thickened,  partly  through 
the  infiltration  present  in  the  submucous 
and  other  coats,  and  partly  in  virtue  of 
a  thickening  of  the  peritoneal  coat;  ad- 
hesions between  adjacent  intestinal  loops 
and  deformation  also  occur.  According 
to  Councilman,  fibrinous  exudation  upon 
the  surface  of  the  mucous  membrane 
(diphtheritic  or  croupus  membrane) 
does  not  take  place  in  uncomplicated 
cases,  while  Kartvilis  describes  its  occur- 
rence. 

The  amcebas  occur  in  greater  or  less 
numbers  in  intimate  association  with  the 
ulcers  and  even  in  adjacent  parts.  They 
are  found  in  the  tissue-spaces,  within  the 
crypts  of  Lieberkuhn,  in  definite  lym- 
phatic vessels,  and  in  the  veins. 

The  mere  presence  of  amosbaa  in  the 
stools  is  not  sufficient  evidence  of  the 
existence  of  amojbic  dysentery.  As  early 
as  1870  Lewis  and  Cunningham  found 
amoebae  in  the  stools  of  persons  sick  of 
cholera  in  India.  They  have  even  been 
found  in  the  stools  of  healthy  persons 
(Grassi,  Kruse  and  Pasquale,  Minckc  and 
Roos,  Schuberg).  Losch  (in  1875)  gave 
the  first  accurate  account  of  the  organism 
which  he  found  in  the  stools  of  a  dysen- 
teric patient,  and  he  studied  the  intestine 
removed  at  the  autopsy.  R.  Koch  ob- 
served amoebffi  in  sections  of  the  intestine 
of  a  number  of  cases  of  dysentery  occur- 
ring in  Egypt  and  India,  and  suggested 
a  causal  relationship  between  them.  Soon 
afterward  (1885)  Kartiilis  was  able  to 
find  them  in  more  than  five  luindrcd 
cases  of  endemic  dysentery   prevailing 


in  Egj'pt,  while  they  were  absent  in  other 
diseases.  Similar  organisms  were  also 
found  in  the  contents  or  walls  of  amrebic 
abscess  of  the  liver.  The  results  of 
Kartulis's  studies  have  been  abundantly 
confirmed  in  this  country  by  Osier,  Coun- 
cilman, Lafleur,  Simon,  Dock,  Eichberg, 
Howard,  Musser,  Stengel,  Flexner,  Wil- 
son, Harris,  and  others. 

The  amajbte  coli  (s.  dysenterias)  re- 
sembles in  many  ways  the  amoebfe  occur- 
ring in  the  stools  of  healthy  beings.  The 
average  size  of  the  latter  is  from  13  to 
36  microns,  of  the  former  from  10  to  50 
microns.  The  structure  of  the  two  forms 
is  also  similar.  In  a  state  of  rest  they 
appear  as  slightly-refractive  and  faintly- 
granular  spheres;  in  the  active  state  a 
separation  into  structureless  ectoplasm 
or  hyaloplasm  and  a  more  refractive, 
granular,  endoplasm  or  granuloplasm 
takes  place.  The  pseudopodia  are  ex- 
truded slowly  and  may  be  easily  ob- 
served; change  of  position  does  not  al- 
ways follow  the  extrusion.  Nuclei  are 
present  and  often  visible,  even  in  the 
fresh  state.  This  description  suffices  for 
the  non-dysenteric  as  well  as  for  the 
dysenteric  varieties;  in  the  latter  there 
is  found,  in  addition,  contained  within 
the  endoplasm,  vacuoles,  bacteria,  and 
red  blood-corpuscles.  The  chief  constit- 
uent, from  a  diagnostic  stand-point,  is 
blood-corpuscles,  as  these  never  occur  in 
the  amoeba3  found  in  healthy  persons; 
both  the  vacuoles  and  bacteria  may,  how- 
ever, be  present.  Nothing  definite  is 
known  of  the  mode  of  propagation,  but 
it  is  believed  that  multiplication  takes 
place  by  division. 

The  amoebiB  are  very  little  resistant; 
the  stools,  etc.,  must,  therefore,  bo  ex- 
amined soon  after  their  evacuation. 
Their  number  quickly  diminishes  in  ma- 
terial outside  the  body,  and  at  the  end 
of  from  six  to  twenty-four  hours  thej 


DYSENTERY.     ETIOLOGY. 


597 


are  often  no  longer  to  be  found.  They 
have  not  been  certainly  successfully  cul- 
tivated outside  the  body  in  a  pure  state, 
although  they  may  have  been  cultivated 
along  with  other  micro-organisms  (Kar- 
tulis,  Celli,  and  Fiocco). 

The  evidences  for  the  belief  in  the 
causal  relationship  between  the  amoeba 
coli  and  endemic  dysentery  is  summed 
up  by  Kartulis  as  follows:  "The  con- 
stant presence  of  the  organism  in  cases 
of  endemic  dysentery  (with  the  excep- 
tion of  the  so-called  'Cochin-China  diar- 
rhoea'; see  below);  its  presence  in  the 
walls  of  the  dysenteric  ulcers  and  absence 
from  other  kinds  of  intestinal  ulcers;  the 
successful  production  of  dysentery  in 
cats  by  the  injection  of  fa;ces  containing 
amcebffi  into  the  rectum  and  even  of  pus 
from  liver-abscesses  free  from  other  mi- 
cro-organisms; the  negative  results  of 
similar  injections  (excepting  in  the  ex- 
periments of  Celli  and  Fiocco)  of  other 
micro-organisms  obtained  from  dysen- 
teric stools;  and,  finally,  the  failure  of 
healthy  stools  containing  amoebiE  to  pro- 
voke dysenteric  lesions  in  cats." 

[The  recognition  of  the  amcebse  in  sec- 
tions of  liardened  tissues  and  their  dis- 
tinction from  swelled  and  degenerated 
tissue-cells  are  not  always  easy.  Alallory 
has  introduced  a  special  staining  method 
in  which  thionin  is  used,  and  Harris  em 
ploys  toluidin-blue,  in  order  to  differ- 
entiate these  organisms  from  other  cells 
Simon  Flexner.] 

The  endemic  dysentery  of  warm  cli 
mates  is  probably  generated  by  aniraa 
parasites,  is  not  contagious,  and  is  some 
times  also  found  in  temperate  regions, 
The  amceba  seems  to  be  the  principa 
factor  in  its  causation,  and  the  patho 
logical  changes  produced  are  most  likely 
due,  in  part  at  least,  to  the  bacteria  de- 
veloped i»  situ  or  transported  there  by 
the  wandering  amceba;.  The  direct  pa- 
thogenic action  of  these  corpuscles  has 
not  yet  been  satisfactorily  established. 


Wegener  (Rivista  Inter.  d'Igiene,  Sept., 
Oct.,  '92). 

There  are  three  forms  of  the  organism: 
(1)  the  Amrcba  coli  fclis  (Losch),  which 
is  the  true  amoeba  of  dysentery;  (2)  the 
AnKLha  coli  mitis,  the  cause  of  the  diar- 
rha^a  in  the  second  case;  and  (3)  the 
Amaba  coli  vulgaris,  the  form  observed 
in  healthy  persons.  Calomel  in  small 
doses  appeared  to  be  the  best  method  of 
reducing  the  number  of  amoeba;  in  the 
stools.  Quincke  and  Eoos  (Berliner  klin. 
Woch.,  No.  45,  '93). 

The  amceba  dysenteriie  is  distinct 
from  the  non-infectious  form,  or  amoeba 
coli.  The  former,  when  coupled  with 
bacteria,  is  the  cause  of  dysentery  and 
of  some  liver-abscesses.  There  still  re- 
main other  liver-abscesses  which  must 
be  classed  as  idiopathic,  and  in  which  cli- 
matic conditions  must  be  looked  on  as 
playing  a  large  part.  Among  the  many 
questions  which  are  yet  to  be  solved 
concerning  the  amoeba;  are  the  following: 
Whether  their  virulence  is  constant  or 
can  be  lost  and  acquired;  how  they  gain 
access  to  the  human  body;  how  the 
bacteria  aid  them;  where  the  bacteria 
come  from;  how  the  dysenteric  ulcers 
begin ;  whether  the  predisposing  causes 
of  cold  and  indigestion  work  on  the 
human  organism  or  on  the  bacteria; 
whetlier  there  is  not  also  a  systemic 
infection,  as  well  as  a  local  process;  in 
what  way  the  amoebae  gain  access  to  the 
liver,  whether  along  the  portal  system, 
the  lymphatics,  the  peritoneum,  or  the 
bilc-passagcs.  There  are  certain  cases 
which  point  to  each  mode,  but  in  multi- 
ple abscesses  the  propagation  is  along 
the  blood-current,  either  from  the 
ulcers  or  backward  from  an  original 
single  focus.  Kruse  and  Pasqualc  (Zeit. 
f.  Hygiene  u.  Infectionskr.,  Feb.  8,  '94). 

Chronic-dysentery  amoebie  are  not 
pathogenic  to  cats  except  when  the  in- 
testinal mucous  membrane  has  been  in- 
jured, as  by  a  sublimate  solution.  The 
amcclice  are  not  the  cause  of  dysentery, 
but  irritants  which  prevent  the  heal- 
ing process  in  lesions  already  existing. 
Kovac  (Zeit.  f.  Heilkunde,  B.  13,  H.  6, 
'94). 

Biological  and  clinical  study  of  235 
cases  of  diarrhoea  and  dysentery.     The 


598 


DYSENTERY.    ETIOLOGY. 


amoeba  found  S6  times,  most  fi-equently 
in  cases  of  typical  diarrlicea,  less  often 
in  simple  catarrhal  enteritis,  and  least 
frequently  in  sporadic  dysentery,  whether 
mild  or  fatal.  The  pathogenic  impor- 
tance of  the  amoeba  denied,  experiments 
upon  cats  having  shown  that  the  amoeba 
swallowed  up  numerous  microbes,  and 
that,  where  amoebte  were  numerous,  but 
a  small  number  of  microbes  were  met 
with.  Opinion  expressed  that  the  amoeba 
prevents  the  development  of  bacteria  and 
permits  healing  of  the  lesions,  thus 
explaining  the  vegetating  form  of  the 
ulcerations  observed  by  Councilman  and 
Lafieur.  The  amoeba  prevents  an  acute 
evolution  of  the  process,  which,  in  turn, 
explains  why  amoebic  dysentery  is  of  a 
chronic  type,  as  assumed  by  many 
authors.  Cassagrande  and  Barbaglio- 
Eapisardi   (Gaz.  degli  Osp.,  No.  Gfi,  '95). 

Cats  injected  with  portions  of  the 
stools  showed  only  a  mild  follicular  en- 
teritis. Small  portions  of  a  dysenteric 
stool  were  mixed  with  peptone  solution, 
and  of  two  cats  injected  at  the  same  time 
with  the  same  stool,  one  remained  liv- 
ing, while  the  other  died  after  six  days. 
There  were  practically  no  differences  in 
their  bowel  changes  from  those  seen  in 
uninjectcd  cats.  The  fifth  and  sixth  eats 
injected  remained  living;  so  that  the 
results  were  not  characteristic.  In  no 
case  were  amoebce  obtained  by  culture, 
or  seen  upon  microscopical  examination. 
A  streptococcus  that  was  obtained,  and 
which  grew  in  the  form  of  a  streptobacil- 
lus,  reacted  to  a  dilution  of  1  to  100 
of  blood-serum  from  the  patients  with 
dysentery,  but  it  reacted  in  just  as  high 
a  dilution  with  the  blood  from  patients 
who  had  no  dysentery.  No  description 
could  cover,  in  a  broad  sense,  the  forms 
that  one  is  likely  to  meet  in  the  contents 
of  the  intestines.  Ascher  (Deut.  med. 
Woch.,  Jan.  20,  '99). 

Conclusions  concerning  the  parasitol- 
ogy of  tropical  dysentery:  1.  No  bacte- 
rial species  yet  described  as  the  cause 
of  dysentery  has  an  especial  claim  to  be 
regarded  as  the  chief  micro-organism 
concerned  in  the  causation  of  the  disease. 
2.  It  is  unlikely  that  any  bacterial 
specicB  that  is  constantly  and  normally 
present   in   the   intestine   or  in   the   en- 


virons of  man,  except  where  the  disease 
prevails  in  an  endemic  form,  can  be  re- 
garded as  the  probable  cause  of  epidemic 
dysentery.  3.  The  relations  of  sporadic 
to  epidemic  dysentei-y  are  so  remote  that 
it  is  improbable  that  the  two  diseases  are 
produced  by  the  same  organic  cause.  4. 
The  pathogenic  action  of  amoeba  coli  in 
many  cases  of  tropical,  and  in  eert-ain 
examples  of  sporadic,  dysentery  has  not 
been  disproved  by  the  discovery  of 
amcebfe  in  the  normal  intestine  and  in 
diseases  other  than  dysentery.  While 
amcebffi  are  commonly  present  and  are 
concerned  in  the  production  of  the  le- 
sions in  subacute  and  chronic  dysentery, 
they  have  not,  thus  far,  been  shown  to 
be  equally  connected  with  the  acute 
dysenteries  even  in  the  tropics.  In  the 
former  varieties  bacterial  association 
probably  has  much  influence  upon  the 
pathogenic  powers  of  the  amceboo.  Simon 
Flexner  (Phila.  Med.  Jour.,  Sept.  1, 1900). 

Six  cases  of  the  ordinary  type  of  so- 
called  amojbic  dysentery,  in  which  the 
blood  did  not  react  with  Shiga's  bacillus. 
This  tends  to  indicate  distinctly  that 
the  disease  is  separate  and  distinct  from 
the  dysentery  as  met  with  in  the 
tropics.  William  Osier  {Jour.  Amer. 
Med.  Assoc,  Jan.  5,  1901). 

No  bacterial  species  yet  described  as 
the  cause  of  dj'sentery  has  an  especial 
claim  to  be  regarded  as  the  chief  micro- 
organism concerned  with  the  disease. 
It  is  imlikely  that  any  bacterial  species 
that  is  constantly  and  normally  present 
in  the  intestine  or  in  the  environs  of 
man,  except  where  the  disease  prevails 
ill  an  endemic  form,  can  be  regarded  as 
a  probable  cause  of  epidemic  dysentery. 
The  relations  of  sporadic  to  epidemic 
dysentery  are  so  remote  that  it  is  im- 
probable that  the  two  diseases  are  pro- 
diiced  by  the  same  organic  cause.  The 
pathogenic  action  of  the  amccba  coli  in 
many  cases  of  tropical  and  in  certain 
examples  of  sporadic  dysentery  has  not 
been  disproved  by  the  discovery  of 
amoeba  in  the  normal  intestine,  and  in 
diseases  other  than  dy.sentery.  While 
amoeba  are  commonly  present  and  are 
concerned  in  the  production  of  the  le- 
sions of  subacute  and  chronic  dysentery, 
they  have  not  thus  far  been  shown  to 


DYSENTERY.    ETIOLOGY. 


599 


be  equally  connected  with  the  acute 
dysenteries,  even  in  the  tropics.  In  the 
former  varieties  bacterial  association 
probably  has  much  influence  on  the 
pathogenic  powers  of  the  amoebiB. 
Simon  Flexner  (Jour.  Amer.  Med. 
Assoc,  Jan.  5,  1901). 

The  most  frequent  complication  of 
dysentery  in  the  Philippine  Islands  is 
malaria.  A  malarial  spleen  and  active 
malarial  parasites  were  found  in  4  out 
of  6G  cases  of  chronic  amoebic  dysentery 
which  came  to  autopsy,  and  once  in  12 
cases  of  subacute  (non-amoebic)  dysen- 
tery. In  157  cases  of  chronic  and  sub- 
acute dysentery  among  soldiers  sick  in 
the  First  Reserve  Hospital,  Manila,  in 
which  blood  examinations  were  made, 
the  malarial  parasites  were  found  in  36, 
or  in  nearly  23  per  cent.  J.  J.  Curry 
(Boston  Med.  and  Surg.  Jour.,  Feb.  21, 
1001). 

^^■llen  the  first  case  of  amcebie  dysen- 
tery was  found  in  Johns  Hopkins,  very 
careful  inquiries  were  made  as  to  the 
patient's  possible  connection  with  things 
tropical.  Now,  however,  that  many 
cases  have  been  seen  there  is  no  ques- 
tion that  the  disease  may  occur  in  those 
who  have  never  been  outside  of  Balti- 
more. The  disease  has  been  observed 
especially  in  children  and  others  who 
have  taken  gutter-water  or  who  have 
had  their  hands  covered  with  material 
from  the  gutters  when  eating.  It  would 
seem,  then,  that  the  frequent  amoeboe 
seen  in  such  water  have  some  connection 
with  the  pathogenic  amoebre.  MacRae 
(Proceedings  Amer.  Med.  Assoc;  Med- 
ical News,  June   14,   1902). 

Complications.  —  Involvement  of  the 
poritonexim  in  the  chronic  cases  with 
deformation  of  the  intestine  has  ah-eady 
been  mentioned;  through  the  formation 
of  adhesions  definite  kinking  of  the 
bowel  may  result.  Perforation  of  the 
bowel,  leading  to  peritonitis,  is  a  rela- 
tively-rare complication,  and  peritonitis 
without  previous  perforation  apparently 
still  rarer.  Small  haemorrhages  in  the 
intestinal  mucosa,  in  the  region  of  the 
ulcers,  are  frequent,  but  large  hremor- 


rhages  seem  uncommon.  In  one  of  Coun- 
cilman and  Lafleur's  cases  about  one  hun- 
dred and  twenty-five  cubic  centimetres  of 
clotted  blood  were  passed  per  rectum  on 
the  last  day  of  illness.  By  far  the  most 
important  complications  are  abscess  of 
the  liver  and  of  the  liver  and  lung.  A 
very  important,  but  unusual,  sequel  of 
liver-abscess  is  perforation  of  the  inferior 
vena  cava.  Flexner  has  described  two 
such  cases.  Although  the  data  at  hand 
for  computing  the  frequency  of  amcebie 
abscess  of  the  liver  in  endemic  dj'sentery 
are,  as  yet,  too  few  to  admit  of  definite 
conclusions,  yet,  according  to  Kartulis 
(based  on  observation  of  500  cases  of 
liver-abscess),  55  to  60  per  cent,  were  of 
dysenteric  origin;  Councilman  and  La- 
fleur  found  liver-abscess  6  times  in  15 
cases,  Kruse  and  Pasquale  6  times  in  57 
cases  of  amoebic  dysentery.  Kartulis 
states  that  liver-abscess,  which  is  so  com- 
mon a  complication  of  endemic  d)'sen- 
tery,  is  infrequent  in  the  epidemic  form. 
Hence  the  statistics  of  British  and 
French  physicians  covering  this  subject, 
in  which  the  proportion  of  1  case  of  liver- 
abscess  for  every  4  or  5  of  dysentery  oc- 
curring in  the  East,  probably  relate 
chiefly  to  the  amcebie  form. 

ITepato-pulmonary  abscess  occurred 
four  times  in  Councilman  and  Lafleur's 
cases.  Following  pulmonary  abscess, 
pleurisy  and  pyothorax  or  pyopneumo- 
thorax (Flexner)  may  supervene.  The 
amoebaj  were  found  in  the  contents  of 
the  hepatic  and  pulmonary  abscesses  and 
pyothorax.  In  abscess  of  the  lung  the 
organism  appears  in  the  sputa.  Kartulis 
has  encountered  abscess  of  the  brain  and 
spleen  in  amoebic  dysentery;  in  neither 
situation  was  he  able  to  demonstrate 
amccbffi. 

The  question  of  the  existence  of 
amoebic  hepatic  abscess  without  evidence 
of  previous  intestinal  lesions  is  still  an 


600 


DYSEKTERY.    COCHIN-CHINA  DIAKKHCEA. 


open  one.  Kruse  and  Pasquale  mention 
two  cases,  but  admit  that  they  are  not 
conclusive.  Flexner  has  described  an  un- 
doubted case.  The  etiologj'  of  the  so- 
called  idiopathic,  or  tropical,  liver-ab- 
scess is  still  wrapped  in  obscurity. 

Kesults  of  examination  in  a  ease  of 
abscess  of  the  liver  follo^ying  dysentery 
in  which  the  amojba  was  found  in  the  pus 
drained  from  the  abscess.  The  amcebse 
from  the  abscess  were  somewhat  larger 
than  those  described  by  Kartulis;  they 
were  circular,  sometimes  ovoid,  but  while 
in  movement  had  an  irregular  outline. 
The  alterations  in  contour  and  change 
in  locality  were  as  remarkable  as  in 
some  forms  of  pond  amoeba;.  Motion 
continued  active  for  hours;  in  two  in- 
stances for  ten  hours.  In  the  stools  the 
amoebae  were  rare  in  the  brownish  liquid; 
more  frequent  in  the  small  sloughs 
passed.  In  form  and  other  characters 
they  were  like  the  organisms  in  the  pus 
from  the  liver-abscess.  Osier  (Johns 
Hopkins  Hosp.  Bull.,  vol.  i,  No.  5). 

Statistics  showing  that  suppurative 
hepatitis  is  almost  always  the  conse- 
quence of  dysentery;  there  is  but  a 
single  pathogenic  element  concerned  in 
the  production  of  both  diseases.  Proof: 
if  dysenteric  faeces  containing  living 
amoebae  be  injected  into  the  rectum  of 
cats  typical  dysentery  will  be  produced, 
the  animals  dying  usually  in  from  thirty- 
nine  hours  to  nine  days,  though  some 
may  survive  and  even  recover;  7  out  of 
1 1  of  those  injected  showed  amoeba;  in 
the  evacuations.  The  classical  altera- 
tions of  dysentery  were  found  at  au- 
topsy. Zancarol  (Le  ProgrOs  MC-d.,  June 
15,  '95). 

Dysentery  in  the  Philippines  has  been 
of  such  a  character  as  to  make  the  fol- 
lowing facts  worth  noting:  1.  Dysen- 
tery, as  it  is  seen  here,  i»  not  a  single, 
but  consist.?  of  two  distinct  and  sepa- 
rate diseases.  2.  Acute  dysentery  does 
not  produce  abscess  of  tlie  liver,  nor 
does  it  produce  ulceration  of  the  colon. 
3.  Its  fatal  result  is  due  to  inflammation 
of  the  bowel,  rapid  elimination  of  the 
watery  fluids  of  the  body,  toxicmia  and 
exhaustion,  much  after  the  manner  of 
cholera,  though  requiring  four,  six,  and 


twelve  days  before  its  termination  or 
crisis.  4.  Amoebic  dysentery  differs 
from  acute  dysentery  anatomically, 
pathologically,  and  etiologically.  The 
only  similarity  between  them  is:  the 
colon  is  the  locus  riiinoris  rcsistentio!  for 
both  the  bacillus  of  Shiga  and  the 
amceba.  Here  all  similarity  ends.  The 
bacillus  of  Shiga  leaves  no  other  lesion 
behind,  save  its  effect  upon  the  mucous 
membrane  of  the  colon  and  enlargement 
of  the  adjacent  glands.  Tlie  amceba  of 
dysentery  invades  the  three  layers  of 
the  colon,  producing  pinched-out  ulcers, 
or  ulcers  with  undermined  edges.  It 
also  passes  to  the  liver  and  produces 
characteristic  lesions.  There  are  two 
varieties  of  the  amceba  which  differ  in 
no  respect  save  as  to  size.  The  pathog- 
enic variety  is  somewhat  larger  than 
the  non-pathogenic.  These  two  varieties 
of  the  amceba  have  been  the  cause  of  all 
the  confusion  regarding  the  amoeba  as 
an  etiological  factor  in  amoebic  dysen- 
tery. Finally,  in  regard  to  the  dysen- 
teries produced  by  the  Shiga  bacillus 
and  amosba:  (1)  the  duality  of  dysen- 
tery is  proved;  (2)  acute  dysentery  is 
the  result  of  infection  with  the  bacillus 
of  Shiga;  (3)  it  is  infectious  in  the  same 
way  as  the  bacillus  of  typhoid  fever 
is  infectious;  (4)  amoebic  dysentery  is 
caused  by  an  amoeba;  (5)  there  are 
both  a  pathogenic  and  a  non-pathogenic 
amoeba,  which  fact  has  produced  much 
confusion  regarding  the  amoeba  as  an 
etiological  factor;  (6)  the  lesions  of 
amoebic  cl3'sentery  differ  from  those  pro- 
duced by  the  bacillus  of  Shiga;  (7)  the 
therapeutic  agents  generally  used  for 
the  treatment  of  acute  dysentery  are  in 
no  way  curative;  (8)  magnesium  sul- 
phate should  be  included  in  this  list; 
(9)  quinine  solution  is  a  specific  for  the 
amoebic  dysentery,  but  its  employment 
in  rapid,  acute,  ulcerating  cases  is 
fraught  with  danger,  and  from  the  na- 
ture of  the  lesions  it  cannot  be  retained 
for  a  sufficient  length  of  time  to  pro- 
duce beneficial  effects.  M.  II.  Bowman 
(Phila.  Med.  Jour.,  from  N.  Y.  Med. 
Jour.,  Aug.  17,  inOl). 

CociiiN-CiiiNA  DiARUHUcA.  —  This  is 
a  form  of  dysentery  which  occurs  in 


DYSEXTERY.    CATAERHAL. 


601 


Cochin-China  and  some  other  tropical 
countries.  Normand  in  1S7G  found,  in 
the  stools  of  soldiers  who  returned  from 
Cochin-China  to  Toulon  and  who  were 
suffering  from  chronic  diarrhoea,  two 
forms  of  nematodes  (Anguillula  slerco- 
ralis  and  Anguilhda  intestinalis)  after- 
ward shown  by  Leuckhart  to  be  the  suc- 
cessive generations  of  a  single  species  to 
which  he  gave  the  name  Rhahdonema 
strongyloides.  Further  studies  have  ren- 
dered doubtful  its  etiological  relation  to 
the  disease.  The  parasite  is  often  absent 
at  the  beginning  of  the  affection,  while 
it  is  not  infrequently  found  in  the  stools 
of  healthy  persons.  Calmette  has  studied 
more  recently  this  form  of  enterocolitis, 
and  has  made  it  probable  that  the  bacil- 
lus pyocyaneus,  alone  or  in  association 
with  the  streptococcus,  is  the  cause  of 
many  cases.  He  also  demonstrated  the 
bacillus  pyocyaneus  in  the  drinking- 
water  at  Saigon  and  Gokong.  Calmette 
was  able  to  produce  hemorrhages  and 
ulceration  of  the  stomach  and  intestine 
in  rabbits  by  injection  of  cultures  of  the 
bacillus  pyocyaneus.  L.  F.  Barker  has 
reported  several  cases,  from  the  Johns 
Hopkins  Hospital,  of  enteric  infection 
and  inflammation  caused  by  this  bacillus. 
In  one  instance  an  extensive  diphtheritic 
inflammation  of  the  oesophagus,  stom- 
ach, and  intestine  existed.  As  a  cause  of 
diarrhoea  and  dysentery  in  infants  it  has 
been  met  with  by  Adami  and  Williams 
in  Canada,  and  of  an  epidemic  of  the 
same  diseases  in  Albany,  N.  Y.,  by 
Blumer  and  Lartigan. 

In  the  case  of  Europeans,  a  large  num- 
ber of  species  of  micro-organisms  found, 
among  which  are  the  colon  bacillus  and 
an  amoeba.  In  natives  (Cochin-Chinese) 
the  number  of  species  is  less  numerous, 
probably  as  a  result  of  the  more  simple 
and  almost  entirely  vegetable  diet.  Two 
species  regarded  as  important  found:  a 
coccus  having  all  the  properties  of  the 
streptococcus  erysipelatous  and  the  bacil- 


lus pyocyaneus.    A.  Calmette  (Archives 
de  MC-d.  Kavalc,  Sept.,  '03). 

The  combination  of  the  colon  bacillus 
and  the  proteus  bacillus  is  the  essential 
cause.  In  northern  Europe  the  epidemic 
is  decidedly  diderent  from  those  seen 
in  tropical  climates.  Chaltin  (Archives 
Med.  Beiges,  Apr.,  '04). 

Catarrhal  Dysentery.  —  This  is  a 
disease  of  the  intestines,  affecting  princi- 
pally the  large  bowel,  which  occurs  spo- 
radically or  epidemically.  It  is  the  form 
of  dysentery  met  with  most  frequently  in 
temperate  climates. 

Morbid  Anatomy  and  Etiology.  —  The 
p.rea  of  intestine  involved  may  be  large  or 
small;  sometimes  the  affection  is  limited 
to  a  circumscribed  area  or  areas,  at  others 
the  mucosa  in  its  entire  extent  is  in- 
volved, even  including  the  stomach.  The 
colon  is  most  often  the  seat  of  the  lesions. 
Woodward  questioned  the  existence  of 
an  isolated  affection  of  the  small  intes- 
tine, while  ISTothnagel  claims  to  have  met 
with  cases  in  which  the  pathological 
process  stopped  abruptly  at  the  ileo- 
caecal  valve,  the  large  gut  having  entirely 
escaped.  The  general  mucosa  and  the 
solitary  lymphoid  nodules,  especially,  are 
affected.  In  the  acute  stage  the  affected 
part  of  the  mucous  membrane  is  red- 
dened, especially  about  the  lymphoid 
nodules  and  plaques,  and  small  extrava- 
sations of  blood  may  appear.  There  is 
an  excessive  production  of  mucus  and  a 
rich  desquamation  of  epithelial  cells. 
The  villi  and  solitary  nodules  are 
swelled,  the  latter  becoming  unduly 
prominent.  The  microscopical  picture 
agrees  with  the  macroscopical  appear- 
ances: there  is  hypera^mia,  swelling,  and 
desquamation  of  epithelial  elements  and 
round-celled  infiltrations  of  the  mucosa. 
The  swelled  lymphoid  nodules  show  an 
increase  in  cells,  the  chief  ones  being  of 
the  large  epithelioid  variety  occupying 
the  germinal  centres.    Extravasations  of 


602 


DYSENTERY.     CATARRHAL. 


blood  are  present  in  the  mucosa  about 
the  nodules.  The  submueosa  shows 
changes  only  in  the  severest  grades.  In 
more  protracted  cases  ulceration,  limited 
to  the  nodules  or  extending  into  the  ad- 
jacent mucosa,  appear.  The  chronic 
cases  are  characterized  by  pallor  of  the 
general  mucous  membrane;  pigmented 
spots  appear,  and  at  one  time  the  mucous 
membrane  is  atrophic,  at  another  hyper- 
trophic. In  the  latter  instance,  in  the 
most  marked  cases,  a  pol)'poid  condition 
of  the  affected  mucous  membrane  may 
exist. 

The  causes  of  this  disease  are  twofold, 
namely:   agents  of  (A)  intoxication  and 
of  (B)  infection.    (.4)  All  caustic  chem- 
ical agents  which  act  directly  upon  the 
mucous  membrane  (acids,  alkalies,  etc.) 
and  others  brought  by  the  blood  and 
eliminated  by  the   intestine   (mercury, 
ricin,  etc.)  and  the  more  indefinite  chem- 
ical substances  which  are  found,  under 
some  circumstances,  in  the  ingested  food. 
(B)  Bacteria  play  an  important  role  in 
the  causation  of  this  disease.     Booker's 
study  of  the  summer  diarrhoeas  of  chil- 
dren is  most  convincing  in  this  respect. 
"Xo  single  micro-organism  is  found  to 
be  the  specific  exciter  of  the  summer 
diarrhffia  of  infants,  but  the  affection  is 
generally  to  be  attributed  to  the  result 
of  the  activity  of  a  number  of  varieties 
of  bacteria,  some  of  which  belong  to 
well-known  species  and  are  of  ordinary 
occurrence   and   wide   distribution,   the 
most  important  being  the  streptococcus 
and  proteus  vulgaris."    As  to  the  mode 
of   entrance   into   the   mucosa,   Booker 
6a)'s:     "In  the  superficial  epithelium  of 
the  intestine  is  apparently  to  be  found 
the    chief    protection    of    the    mucosa 
against  the  invasion  of  bacteria.    When 
the  epithelium  is  preserved,  bacteria  are 
not    found    in    the    mucosa    beneath, 
whereas  they  may  be  seen  entering  it  in 


places  where  the  epithelium  has  been 
lost  or  injured."  Gartner's  bacillus  en- 
teriditis  is  capable  of  provoking  acute  en- 
teritis; and  acute  enterocolitis  is  asso- 
ciated as  a  secondary  affection,  with  a 
variety  of  specific  infections  (cholera,  ty- 
phoid fever,  tuberculosis),  intestinal  dis- 
eases, and  other  infectious  processes 
(sepsis,  influenza,  pneumonia,  scarlet 
fever,  measles,  diphtheria,  etc.). 

Seven  cases  of  endemic  dysentei-y  in 
•wliich  a  large  aerobic  bacillus  was 
isolated.  It  developed  well  on  ordinary 
culture-media,  liquefying  gelatin,  curd- 
ling milk,  and  producing  gas.  It  is 
motile,  somewhat  like  anthrax  morpho- 
logically, but  is  decolorized  by  Gram's 
method.  Inoculated  into  animals,  it 
produces  a  htemorrhagic  septiccemia  with 
ulceration  of  the  colon.  Roger  (Comp. 
Rend,  de  Biol.,  ser.  xi,  1,  '99). 

The  specific  cause  is  an  organism  much 
like  the  bacillus  coli,  and  which  is  agglu- 
tinated by  the  blood  of  dysenteric  pa- 
tients. An  antitoxic  serum  prepared 
with  which  266  eases  were  treated,  with 
a  death-rate  of  12  per  cent.,  the  death- 
rate  during  the  same  period  under  ordi- 
nary treatment  in  1736  cases  being  34 
per  cent.  Shiga  (Report  by  Surgeon 
Eldridge  to  the  U.  S.  Marine-Hosp.  Serv- 
ice, 1900). 

In  Fiji  dysentery  is  endemic  and  most 
prevalent  in  May,  June,  and  July:  the 
season  of  di-y  weather  and  scanty  water- 
supply.  While  under  some  circumstances 
tlie  mortality  is  high, — 40  per  cent., — the 
average  death-rate  is  7  per  cent.  C.  W. 
Hirsch  (Edinburgh  Med.  Jour.,  Jan., 
1900). 

Among  277,000  eases  of  malarial  dis- 
ease recorded  by  various  writers,  3054 
were  registered  as  pernicious  fever,  and, 
of  the  1317  of  those  which  were  more 
definitely  classified,  only  8  were  consid- 
ered to  be  as  belonging  to  the  pei-nioioua 
dysenteric  class.  Knnallis  and  Carda- 
niatis  (Prngn-'s  MOd.,  May  19,  1000). 

In  Manila  dysentery  is  very  common. 
Investigation  has  conclusively  shown  the 
two  types  of  dysentery:  one  dependent 
upon  a  si)eciflc  bacillus  said  to  resemble 
the    bacillus    typhosus    or    the    bacillus 


DYSENTERY.     CATARRHAL. 


603 


eoli  communis,  the  other  being  the  ordi- 
nary amoibic  dysentery  of  the  tropics. 
R.  P.  Strong  and  W.  E.  Musgrave  (Jour. 
Amer.  Med.  Assoc,  Aug.  25,  1900). 

Analysis  of  the  waters  of  Landerncau 
(Brittany)  in  the  midst  of  an  affected 
region.  The  nutritive  gelatin  plates  of 
Ellsner  showed  colonies  of  the  colon 
bacillus,  the  method  of  P6r6  also.  The 
bacillus  resembled  Eberth's  bacillus,  but 
was  distinguished  by  the  lactose  test, 
which  difTcred  from  the  reaction  with 
Eberth's  bacillus.  F.  Lenoble  (La  Prosse 
M6d.,  Oct.  27,  1900). 

Comparative  study  of  several  cultures 
of  bacilli  obtained  from  cases  of  dysen- 
tery. These  organisms  were  designated 
Manila  cultures,  Kruse's  bacillus,  Shiga's 
bacillus,  cultures  of  a  Porto  Rican,  and 
Strong's  bacillus.  The  differences  of 
growth  are  slight,  and  probably  depend 
upon  purely  accidental  circumstances. 
A  comparison  of  the  morphologj'  of  the 
bacilli  shows  only  very  minor  differ- 
ences. Kruse  has  not  observed  motility 
at  any  time  in  liis  culture;  Shiga  states 
his  to  have  been  feebly  motile,  while 
those  of  the  author  were  at  first  slightly 
motile,  but  soon  became  quiescent  in 
artificial  cultivation  and  did  not  regain 
motility.  Strong's  observations  coincide 
with  the  author's.  Vedder  and  Duval, 
under  the  direction  of  the  author,  have 
succeeded  in  demonstrating  flagella  by 
Van  Ennengheim's  method  in  several 
cultures.  The  serum  reactions  have 
been  of  the  greatest  importance,  and 
are,  moreover,  unmistakable  in  signifi- 
cance; they  indicate  close  relationship 
between  the  bacilli  from  Japan,  Manila, 
Porto  Rico,  and  Germany,  and  they 
further  render  probable  the  identity  of 
the  epidemic  dysentery  of  this  country 
with  that  of  the  East  and  Germany. 
Flexner  (Brit.  Med.  Jour.,  Sept.  21, 
1901). 

Shiga's  bacillus  dysentcria;  is  found  in 
the  latter  half  of  the  first  week  of  the 
disease  in  the  fresh  stools;  in  the  later 
stages  of  the  disease  it  is  rather  difficult 
to  cultivate.  It  disappears  more  or  less 
completely  ns  the  patient  improves.  If 
there  is  a  relapse  it  again  appears  in 
large  numbers.  One  finds  the  bacilli  in 
almost  pure  culture  in  fresh  catarrhal 


or  diphtheritic  areas  in  the  bowel;  in 
fresh  conditions  they  are  found  more 
superficially  in  the  lesions;  in  the  old 
infection,  the  colon  bacillus  and  other 
micro-organisms  overgrow  them.  The 
bacilli  are  often  found  in  the  mesenteric 
glands,  but  the  author  has  never  found 
them  in  the  liver  or  spleen.  He  exam- 
ined five  cases  of  parotitis  which  oc- 
curred in  the  course  of  dysentery,  and 
was  unable  to  find  the  bacilli  in  ex- 
tirpated portions  of  the  glands  or  in 
juices  of  the  gland.  The  urine,  blood, 
and  milk  are  always  sterile.  Because  of 
the  localized  character  of  the  disease 
one  finds  in  dysentery  no  tumor  of  the 
spleen,  no  eruption,  and  no  infiararaa- 
tory  conditions  of  the  bone  and  bone- 
marrow,  etc.,  such  as  are  found  in  ty- 
phoid fever.  The  agglutinative  reaction 
he  has  tested  in  hundreds  of  patients 
and  found  it  generally  parallel  in  in- 
tensity with  the  severity  of  the  disease. 
It  appears  in  some  instances  in  dilution 
as  great  as  1  to  130,  and  so  on  down, 
very  mild  cases  being  negative  at  1  to 
10.  He  has  seen  the  reaction  present 
as  long  as  eight  months  after  the  at- 
tack. Jt  is  now,  however,  of  impor- 
tance in  diagnosis  in  many  instances, 
because  it  is  very  likely  to  be  absent 
in  very  mild  or  doubtful  cases.  He  dis- 
cusses the  relation  between  the  typhoid 
serum  reaction  and  the  prognosis,  and 
then  states  that,  after  making  quan- 
titative investigations  on  the  agglu- 
tinating power  of  the  blood  in  dysen- 
tery, be  found  that  its  intensity  is  prac- 
tically parallel  with  the  severity  of  the 
disea.se  excepting  in  very  grave  cases, 
which  are  commonly  fatal,  in  which  the 
reaction  is  usually  but  slightly  marked. 
Agglutination  appears  only  in  the  sec- 
ond or  third  week  of  the  disease,  and 
reaches  its  highest  point  in  convales- 
cence. It  sometimes  appears  as  late  as 
the  sixth  week,  and  this  late  appear- 
ance makes  it  of  little  importance  in 
diagnosis.  The  bacteriological  diagnosis 
of  a  case  of  dysentery  may  be  made  by 
carrying  out  the  agglutination  test  of 
a  culture  with  immune  scrum,  by  culti- 
vating on  glucose  agar,  and  in  milk. 
If  agglutination  occurs  at  once,  if  there 
is  no   gas-production,  and   if   milk   has 


604 


DYSENTERY.    DIPHTHERITIC. 


not  coagulated,  the  dysentery  bacilli 
may  be  considered  to  be  present.  K. 
Shiga  (Deutsche  med.  Wochen.,  Oct.  24, 
1901). 

Dysentery  is  due  to  the  increase  in 
the  \-irulence  of  micro-organisms  that 
ordinarily  inhabit  the  intestine.  The 
writer  does  not  consider  it  due  to  a 
specific  organism.  Bertrand  {Revue  de 
Jled.,  July  10,  1902). 

DiPHTHEBiTic  Dtsenteet.  —  An  in- 
flammatory disease  of  variable  and  un- 
certain etiologj',  which  affects  especially 
the  large  intestine,  sometimes  involving 
the  small  gut,  which  may  or  may  not  be 
attended  with  fever;  is  characterized  by 
mucous,  serous,  or  bloody  stools,  and  is 
accompanied  with  tormina  and  tenesmus. 
The  anatomical  lesions  consist  of  necrosis 
of  the  mucous  membrane,  the  deposit 
within  its  substance  and  upon  its  surface 
of  a  fibrinous  pseudomembrane,  and  the 
formation  of  ulcers.  This  occurs  (a)  as 
a  primary  disease,  in  which  form  it  prob- 
ably gives  rise  to  the  great  majority  of 
the  cases  of  epidemic  dysentery;  (&)  as 
a  secondary  and  terminal  affection  in 
many  acute  and  chronic  diseases,  the 
chief  ones  being  acute  general  infections 
and  chronic  renal,  cardiac,  and  hepatic 
disease.  Certain  cases  of  sporadic  dysen- 
ierij,  the  result  of  the  action  of  chemicals 
and  metastatic  bacteria  upon  the  intes- 
tinal mucous  membrane  and  indirectly 
of  mechanical  irritants  (coprostasis,  in- 
testinal worms),  belong  to  this  class. 

Morhid  Anatomy  and  Etiology. — The 
pathological  process  begins  with  hyper- 
emia and  swelling  of  the  submucosa  and 
mucosa.  The  unique  character  of  the  dis- 
ease begins  with  the  appearance  of  small 
grayish-white  membranous  patches  upon 
the  surface  of  the  mucous  membrane. 
These  increase  in  size  and  become  con- 
fluent. At  first  they  are  readily  removed 
with  the  finger;  at  a  later  stage  they  are 
more  adherent.     They  tend  to  appear, 


by  preference,  upon  the  more  prominent 
and  projecting  parts  of  the  mucosa;  thus, 
in  the  small  intestine  along  the  tips  of 
the  valvule  conniventes;  in  the  large, 
corresponding  with  the  insertion  of  the 
longitudinal  muscular  bands.  At  a  later 
time  and  in  severe  cases  the  intervening 
mucous  membrane  may  become  covered. 
Upon  microscopical  examination,  in  the 
earliest  stages  of  the  disease  the  blood- 
vessels of  the  submucous  and  mucous 
coats  are  congested  and  contain  an  in- 
creased number  of  polymorphonuclear 
leucocytes;  the  superficial  epithelial 
layer  is  necrotic,  and  fibrin  and  leuco- 
cytes are  present  on  the  injured  surface. 
Somewhat  later  the  necrosis  has  ex- 
tended and  involved  the  deeper  parts — 
glands  and  interglandular  tissue — and 
the  fibrinous  membrane  is  thicker  and 
intimately  bound  up  with  the  necrotic 
tissue.  Many  kinds  of  bacteria  are  pres- 
ent in  the  necrotic  and  exudative  ma- 
terial. The  swelling  of  the  submucosa 
may  reach  a  high  degree,  due  to  oedema, 
cellular  infiltration,  and  a  deposit  of 
fibrin.  The  blood-vessels  of  the  mucous 
membrane  become  plugged  by  hyaline 
thrombi.  The  separation  of  the  dead 
tissue  leaves  an  ulcer  behind.  The  young 
ulcers  do  not  extend  deeper  than  the 
submucosa  coat;  later,  and  by  continued 
destruction,  the  muscular  coat  may  be 
exposed.  Perforation  of  the  intestines 
is,  in  this  form  of  dysentery,  unusual. 
Ecchymoses  occur  in  the  neighboring 
mucosa.  Even  the  deepest  ulcer  may, 
through  the  formation  of  granulation- 
tissue,  heal.  In  these  cases  the  wall  of 
the  intestine  becomes  thickened;  the 
muscle  hypertrophic;  the  scars  have  a 
pigmented  appearance,  and,  through  re- 
traction of  the  cicatricial  tissue,  de- 
formity and  often  stenosis  of  the  bowel 
arise. 

'J'hc  points  of  pi'cdilcction  of  the  path- 


DYSENTERY.    DIPHTHERITIC. 


605 


ological  process  are  the  flexures  (sigmoid, 
splenic,  hepatic),  the  ascending  colon, 
and  caecum.  In  the  Crimean  War  the 
rectum,  sigmoid  flexure,  and  descending 
colon  were  the  principal  points  of  attack. 
The  small  intestine  is  only  rarely  affected 
in  its  lowest  parts,  and  this  in  severe 
cases;  in  certain  secondary  forms  of  dys- 
entery it  may  be  attacked  alone. 

Klebs  was  the  first  to  describe  short 
bacilli  in  the  crypts  of  Lieberkuhn  in 
diphtheritic  dysentery.  Since  this  time 
a  large  number  of  bacteria  have  been 
described  in  association  with  the  disease. 
None  of  these  appear  to  be  specific,  and 
the  circumstances  of  the  disease  make  it 
easy  to  isolate  different  bacterial  forms. 
From  what  has  already  been  said  it  is 
not  probable  that  diphtheritic  dysentery 
is  caused  by  a  single  micro-organism. 
As  regards  the  question  of  etiology  of 
epidemics,  whether  in  a  given  epidemic 
a  single  species  of  micro-organism  is  to 
be  regarded  as  the  cause,  and  in  different 
and  widely-removed  ones  the  same  spe- 
cies will  be  found,  cannot  be  answered 
at  present.  Thus  far  a  very  small  num- 
ber of  epidemics  have  been  studied  with 
modern  bacteriological  methods. 

Zieglcr  described  small  bacilli  in  the 
crypts  of  Lieberkuhn  and  the  underly- 
ing mucous  membrane.  Marfan  and  Lion 
cultivated  from  the  mesenteric  glands, 
pericardial  fluid,  and  heart's  blood  of 
two  cases  the  bacillus  coli  communis. 
Babes  has  cultivated  the  streptococcus, 
proteus  vulgaris,  and  other  organisms 
from  dysenteric  cases.  Maggiori  studied, 
in  1891,  an  epidemic  which  occurred 
in  Italy.  He  found  in  the  mucous  stools 
of  all  cases  the  bacillus  coli  communis, 
in  association  with  proteus  vulgaris. 
More  rarely  pyococci,  bacillus  fluores- 
cens,  and  pyocyaneus  were  obtained. 
Ogata  investigated  an  epidemic  which 
prevailed  in  Japan.    He  found  small  ba- 


cilli, which  lay  in  the  protoplasm  of  cells; 
they  were  present  in  the  base  of  the 
ulcers.  Cultures  from  fifteen  cases  gave 
a  short,  non-pathogenic,  liquefying  ba- 
cillus. From  eleven  cases  Ogata  culti- 
vated a  bacillus  which  also  liquefied 
gelatin,  but  was  pathogenic.  Guinea- 
pigs,  inoculated  subcutaneously,  develop 
haemorrhages  and  ulcers  in  the  intestine. 
Rectal  injections  produced  more  pro- 
nounced results.  Condorelli,  Maugieri 
and  Aradas  describe  a  bacillus  which  they 
obtained  from  an  epidemic  and  also  iso- 
lated from  the  drinking-water;  Bertrand 
and  Baucher  studied  an  epidemic  at 
Cherbourg  and  isolated  several  different 
bacteria,  none  of  which  appear  to  be  spe- 
cific. Silvestri  described  diplococci  which 
caused  diarrhoea  in  dogs.  Colli  and  Fi- 
occo  found  that  in  the  dejections  of  dys- 
enteric persons  the  bacillus  coli  com- 
munis is  always  present;  with  it  is  often 
associated  a  typhoid-like  bacillus;  more 
rarely  the  streptococcus  and  proteus  ba- 
cillus. The  introduction  of  this  bacillus 
coli,  either  alone  or  in  association  with 
the  other  bacteria,  by  means  of  the  mouth 
or  rectum,  into  cats,  gives  rise  to  dysen- 
tery. According  to  these  writers,  the 
association  of  the  bacillus  coli  communis 
with  the  other  bacteria  mentioned  leads 
to  its  conversion  into  the  bacillus  coli 
dysenteric.  Celli  has  more  recently  ex- 
pressed the  idea  that  the  primary  in- 
jury to  the  intestine  is  produced  by  the 
toxin  of  the  bacillus  dj'senterie,  which  is 
followed  by  the  injurious  action  of  pyo- 
genic cocci  contained  within  the  intes- 
tine. Ciechanowski  and  Norrak  have 
failed  to  confirm  this  view  by  experi- 
ments, although  they  found  large  num- 
bers of  streptococci  in  the  stools  of  cases 
of  sporadic  dysentery.  The  bacillus  pyo- 
cyaneus, according  to  Blumer  and  Larti- 
gan,  may  be  associated  with  epidemics  of 
dysentery  in  this  country. 


606 


DYSEXTERY.     TREATMENT. 


Treatment. — The  hygienic  rules  which 
are  observed  in  the  prevention  of  other 
infectious  diseases  and  especially  of 
cholera  have  been  employed  with  excel- 
lent effect  in  controlling  epidemics  of 
dysentery.  The  emplo}Tnent  of  filtered 
and  boiled  water  has  reduced  the  num- 
bers of  cases  and  the  spread  of  the  dis- 
ease in  the  tropics.  The  same  principles 
are  applicable  to  the  treatment  of  articles 
of  food  (vegetables,  fruits,  etc.)  which 
come  into  contact  with  water.  Other 
prophylactic  measures  consist  in  the  use 
of  suitable  clothing  which  obviates  the 
injurious  influence  of  rapid  changes  in 
temperature  and  humidity  of  the  air  and 
the  proper  disposition  of  the  dejecta  from 
the  sick. 

In   armies   in   the   field    intemperance 
and  all  forms  of  excess  should  be  severely 
repressed.    For  the  purification  of  water 
everj'  available  method  should  be  used, 
but  the   most  practical   and   certain   is 
boiling.     Soldiers  willingly   adopt   these 
precautions  if  tea  or  coffee  is  served  out 
to  them  for  use  with  the  water.    As  the 
sanitary  service  is  not  adequate  to  cope 
with  the  necessary  work  of  disinfecting 
hospitals   and   the  sanitation   of   battle- 
fields, there  should  be  organized  in  time 
of  peace  a  special  service  for  those  pur- 
poses which  should  be  in  a  condition  to 
set  to  work  from  the  very  beginning  of 
mobilization.    A  service  of  this  kind  was 
tried  with  success  by  the  Russians   in 
1877.     Antony    (Thirteenth   Inter.  Med. 
Congress;     Brit.    Med.    Jour.,    Sept.    8, 
1900). 
The  direct  treatment  is,  in  part,  di- 
etetic ,  in   part   therapeutic.     In   acute 
cases  the  diet  is  to  be  restricted  to  milk, 
whey,  and  broths,  and  during  convales- 
cence great  care  is  to  be  exercised  in  pro- 
viding only  the  most  digestible  articles 
of  food.     In  the  use  of  a  diet  of  milk, 
which  often  will  be  the  chief  article,  the 
appearance  of  curds  in  the  stools  is  the 
indication  to  dilute  or  partially  peptonize 
the  milk  before  it  is  administered.    Di- 


luted egg-albumin  may  supplement  milk 
or  even  take  its  place  for  a  few  days  if 
there  is  much  intolerance  to  the  latter. 
Sometimes  milk  is  made  more  acceptable 
by  dilution  with  lime  or  Vichy  water. 
The  quantity  of  milk,  for  an  adult,  ad- 
ministered in  twenty-four  hours  should 
be  from  2  to  3  ^/„  quarts.  Whatever  the 
food,  it  is  advisable  to  give  it  in  small 
quantities  and  at  frequent  intervals. 

The  patient  even  in  chronic  cases 
should  be  confined  to  bed;  in  acute  cases 
no  especial  persuasion  will  be  required. 
For  the  relief  of  the  abdominal  pain,  the 
external  application  of  fomentations  or 
turpentine  stupes  will  sometimes  suffice; 
but  the  internal  use  of  opiates  may  be 
demanded.  AVlien  the  pain  is  low  down 
in  the  bowel  then  enemata  of  opium  or 
suppositories  containing  some  form  of 
this  drug  or  of  cocaine  may  be  resorted 
to. 

"When  a  case  is  seen  earlj',  especially  if 
there  has  been  constipation,  a  purge 
should  be  administered.  This  can  be 
either  castor-oil  or,  what  is  preferable,  a 
saline.  By  this  means  the  frecal  contents 
of  the  large  intestine,  which  tend  to  pass 
continuously  over  the  inflamed  area, 
should  be  efl'ectually  removed.  The 
saline  selected  should  be  given  in  suf- 
ficient doses  to  promptly  produce  abun- 
dant dejections,  and  it  is  then  to  be  dis- 
continued. There  may  be  a  marked  dim- 
inution in  the  frequency  of  the  dysen- 
teric evacuations,  and  great  relief  of  the 
tormina  and  tenesmus  following  the 
operations  of  the  purgative.  The  use  of 
a  saline  is  contra-indicated  by  feebleness 
of  the  patient;  in  such  cases  castor-oil 
is  to  bo  preferred. 

Nincty-flvo  cases  treaicd  at  llydera- 
liad,  India,  by  sulphate-ot-magnesium 
iiietliod.  The  number  of  days  under  this 
licatment  before  the  dysenteric  synip- 
tmim  disappeared  was  never  more  than  5, 


DYSENTERY.    TliEATMEXT. 


607 


and  in  many  eases  1  or  2  only.  Leahy 
(Lancet,  Oct.  4,  '00). 

[Saturated  solutions  of  magnesium 
sulphate  urged  by  many  observers:  To 
an  ounce  of  saturated  solution  of  mag- 
nesium sulphate  10  drops  of  dilute  sul- 
phuric acid  are  added;  this  is  given 
every  hour  or  two  until  it  operates  freely 
and  the  stools  have  become  feculent,  free 
from  blood  and  nuicus,  and  the  pain  and 
tenesnu)s  are  relieved.  W.  W.  John- 
ston, Assoc.  Ed.,  Annual,  '91.] 

Mortality  reduced  from  5  to  10  per 
cent,  to  practically  7iil,  by  avoiding  all 
irritants  and  stimulants;  rendering  the 
intestinal  canal  aseptic  by  preventing  the 
decomposition  of  contents;  by  counter- 
acting acidity  of  the  blood  by  alkalies 
and  thus  quieting  the  abnormal  action 
of  the  intestinal  glands.  Diet  restricted 
to  arrowroot-milk  and  trinitrate  of  bis- 
nuith,  Dover's  powder,  and  soda  inter- 
nally. Bahadurji  (Brit.  Med.  Jour.,  Oct. 
24,  '91). 

Drachm-doses  of  a  saturated  solution 
of  Epsom  salts,  in  combination  with  10 
minims  of  dilute  sulphuric  acid,  every 
hour,  are  strikingly  cfTcetive.  V.  G. 
Thorpe   (Brit.  Med.  Jour.,  Feb.  2G,  '98). 

Sulphate  of  soda  or  sulphate  of  mag- 
nesia may  be  given  in  drachm  doses 
evei-j'  quarter-  to  half-  hour  for  the 
first  four  or  six  doses,  and  afterward  at 
longer  intervals  until  the  motions  assume 
a  good  yellow  color.  With  the  saline  a 
little  quinine  and  perchloride  of  mercury 
may  be  combined  if  desired.  Scries  of 
555  consecutive  cases  treated  in  this  way, 
with  only  G  deaths.  For  chronic  or  re- 
lapsing cases  the  saline  treatment  is  not 
nearly  so  efUcacious,  and,  after  one  or 
two  doses  of  the  salt,  castor-oil,  bismuth, 
etc.,  should  be  given.  Buchanan  (Brit. 
Med.  Jour.,  i,  p.  30G,  1900). 

Salines  used  in  855  cases  in  Bengal. 
There  were  only  9  deaths:  a  mortality 
of  only  a  little  over  1  per  cent.  The 
following  mixture  was  used: — 

B  Sodii  sulphatis,  1  drachm. 
Aquae  foeniculi,  ad  1  ounce. 

This  was  given  four,  six,  or  eight 
times  a  day  (each  dose  represented  1 
drachm  of  the  saline)  as  the  case  re- 
quired.    No  dose  was  repeated  on  the 


following  day  till  the  stool  had  been  in- 
spected. The  saline  was  continued  till 
every  trace  of  blood  and  mucus  had  dis- 
peared  completely  in  two  or  three  days; 
in  others  they  returned  on  the  third 
or  fourth  day,  necessitating  a  repetition 
of  the  saline. 

The  saline  treatment  is  advocated  for 
acute  cases  only.  It  is  not  considered  a 
safe  method  for  chronic  or  relapsing 
cases  with  ulceration  of  the  colon.  In 
cases  in  which  either  the  symptoms  or 
the  history  point  to  the  disease  being 
either  chronic  or  relapsing,  the  saline 
was  used  for  one  or  two  doses  during  an 
exacerbation  of  the  chronic  state,  and 
then  the  case  was  treated  with  soda 
and  bismuth  or  with  salol,  with  an  occa- 
sional dose  of  castor-oil.  For  stools 
containing  seybala  nothing  is  so  good 
as  a  dose  of  castor-oil  guarded  by  10 
minims  of  laudanum. 

When  the  patient  can  be  admitted  to 
hospital,  the  saline  is  the  best  method 
of  treating  acute  dysentery,  but  it 
should  not  be  applied  in  a  routine 
fashion  in  out-patient  practice,  on  ac- 
count of  the  possibility  of  many  patients 
having  had  previous  attacks,  and  hav- 
ing their  bowels  in  a  state  of  unhealed 
ulceration.  The  success  which  has  this 
year  attended  the  treatment  of  the 
chronic  cases  in  due  to  careful  dieting 
on  rice-water  (mar),  and  boiled  milk 
and  tyre  (dahi),  the  use  of  anthelmin- 
tics (a  large  proportion  of  the  inhabit- 
ants of  this  part  of  Bengal  harbor  both 
round  and  tape-  worms),  and  the  careful 
occasional  use  of  the  saline,  with 
Dover's  powder  and  the  intestinal  anti- 
septics. W.  J.  Buchanan  (Brit.  Med. 
Jour.,  Apr.  13,  1901). 

The  oldest  method  of  treating  dysen- 
tery which  has  been  found  at  all 
successful  is  that  by  a  large  dose  of 
calomel.  The  next  treatment  in  point  of 
time  was  castor  oil — an  exceedingly  good 
one.  Then  came  the  administration  of 
ipecacuanha,  in  doses  of  30  grains  of 
powder.  In  the  recent  epidemic  in  South 
Africa  the  remedies  most  in  favor  were 
magnesium  sulphate  and  sodium  sul- 
phate. In  many  .subacute  cases  nothing 
acts  so  well  as  a  change  of  scene  or 
climate.    Brunton  (Lancet,  July  4,  1903). 


608 


DYSEN'TERY.    TREATilENT. 


Among  the  drugs  used  to  combat  the 
disease,  ipecacuanha  still  maintains  its 
reputation  in  the  tropics.  It  is  usually 
administered  after  a  preliminary  dose  of 
laudanum  or  morphine,  which  is  followed 
in  half  an  hour  by  from  20  to  60  grains  of 
ipecaeijanha.  Should  the  dose  be  re- 
jected, it  is  repeated  in  a  few  hours.  This 
mode  of  treatment  was  not  satisfactory 
during  the  TVar  of  the  Eebellion,  and 
Osier  has  failed  to  see  in  sporadic  cases 
the  marked  effects  claimed  for  it  by  the 
physicians  in  the  tropics. 

Experience  in  Bengal  has  given  great 
faith  in  ipecacuanha  in  large  doses. 
Castor-oil  should  be  given  the  night  be- 
fore and,  after  the  bowels  have  moved  in 
the  early  morning,  tincture  of  opium,  fol- 
lowed in  fifteen  or  twenty  minutes  by 
ipecacuanha  in  a  dose  of  25  or  30  grains. 
The  patient  should  lie  undisturbed  for 
four  or  five  hours.  Should  vomiting  oc- 
cur, ipecacuanha  to  be  repeated  in  half 
an  hour  and  also  if  the  stool  has  not 
much  changed  for  the  better  within 
twenty-four  hours.  Ipecacuanha  in  pill, 
in  doses  of  from  3  to  5  grains,  is  utterly 
useless.  W.  J.  Buchanan  (Practitioner, 
Dec.,  '97). 

Ipecacuanha  tried  several  years  in 
Nicaragua,  Central  America.  Notwith- 
standing its  vaunted  efficacy,  no  case  de- 
rived much  benefit  from  it.  Patients  suf- 
fering from  dysentery  cannot  always 
retain  large  doses,  as  stated  in  text- 
books. Half-ounce  doses  of  a  saturated 
solution  of  magnesium  sulphate  and  15 
minims  of  dilute  sulphuric  acid  every  two 
hours,  with  milk  diet,  caused  all  traces 
of  blood  to  disappear  from  the  stools  in 
twenty-four  hours,  and  there  was,  of 
course,  a  complete  absence  of  the  dis- 
tressing nausea  which  is  always  present 
in  the  treatment  of  ipecacuanha.  T.  R. 
Wiglesworth  (Brit.  Med.  Jour.,  Feb.  26, 
•98). 

Ipecac  ia  indicated  in  almost  every 
form  and  type  of  acute  dysentery  owing 
to  its  simplicity,  its  safety,  and  its 
certainty,  compared  with  any  other 
method.  The  promptitude  with  which 
the  inflammation  is  stopped.  The  rapid- 
ity with  which   repair  takes  place   (a) 


by  resolution  or  (h)  by  granulation  and 
cicatrization.     Conservatism  of  the  con- 
stitutional powers.  Abbreviation  of  the 
period  required  for  convalescence.     De- 
crease  in   the   frequency   of  recvu'rence. 
Decrease  in  the  frequency  of  abscess  of 
the  liver.     Diminution  of  mortality  in 
cases   treated.     The  chief   objection   to 
ipecac  is  its  frequent  rejection  from  the 
stomach.    Its  administration  in  the  form 
of  compressed  pills  coated  with  salol  is 
recommended    to    avoid    this    untoward 
feature.     William  Roberts  (Jour.  Anier. 
Med.  Assoc,  April  11,  1903). 
Corrosive  sublimate,  in  doses  of  Vioo 
grain,  repeated  every  two  hours,  has  been 
recommended  by  Ringer.     Bismuth  in 
large  doses — Va  to   1  drachm  every  2 
hours,  amounting  to  12  to  15  drachms 
in  24  hours — often  has  a  beneficial  effect. 
Its  effects  are  more  pronounced  in  the 
chronic  than  in  the  acute  cases. 

The  administration  of  antiseptic  sub- 
stances by  the  mouth  for  the  purpose  of 
disinfecting  the  intestinal  canal  has  been 
emploj'ed.  For  this  purpose  benzo- 
naphthol  is  the  drug  to  be  chosen  when 
there  is  suspicion  of  liver  or  kidney  dis- 
ease, and  in  their  absence  it  is  as  effective 
as  betanaphthol  and  resorcin,  which  are 
also  employed  as  intestinal  antiseptics. 
The  dose  of  benzonaphthol  is  40  to  80 
grains,  given  during  24  hours,  in  divided 
doses  every  2,  3,  or  4  hours.  Betanaph- 
thol and  resorcin  are  given  in  quanti- 
ties of  from  30  to  50  grains  in  24  hours 
in  much  the  same  way.  The  naphthol 
preparations,  being  insoluble,  must  be 
given  in  capsules  or  dissolved  in  oil  and 
emulsified.  Resorcin  is  soluble  and  can 
be  readily  administered.  Naphthalin  (20 
grains  per  day)  and  salol  (30  to  40  grains 
per  day)  are  used  for  the  same  purpose. 
Opium  is  an  invaluable  remedy  for  the 
relief  of  pain  and  to  quiet  the  peristalsis, 
but  should  l)c  employed  cautiously.  It 
is  to  be  administered  hypodermically  in 
the  form  of  morphine,  according  to  tlie 
needs  of  the  patient. 


DYSENTERY.    TREATMENT. 


609 


Sulphur  successfully  used  in  the  treat- 
ment of  dysentery.  Twenty  grains  of 
sublimed  sulphur  are  combined  with  5 
grains  of  Dover's  powder;  to  be  given 
four-hourlj'.  In  all  of  the  cases  that 
have  been  treated  with  sulphur  the  re- 
covery has  been  rapid  and  the  patient 
has  seemed  to  derive  relief  more  speed- 
ily from  his  pain  and  straining  than 
with  other  methods  of  treatment.  The 
cure  with  sulpliur  seems  to  be  more  cer- 
tain and  stable,  as  chronic  conditions 
and  relapses  have  not  occurred.  Blood 
and  mucus  are  easily  stopped  and  the 
motions  quickly  become  faecal.  In  some 
cases  the  number  of  motions  per  diem 
did  not  at  once  diminish,  but  the  pain 
and  straining  were  lessened  and  the 
character  of  the  motions  became  more 
feecal  and  contained  little  or  no  blood. 
Aa  soon  as  the  diarrhoea  becomes  less, 
it  is  advisable  to  give  the  powders  less 
frequently.  G.  E.  Richmond  (Lancet, 
June  15,  1901). 

Three  acute  and  fifteen  chronic  cases 
of  amoebic  dysentery  were  treated  with 
sulphur  of  natural  spring  in  the  Philip- 
pines. The  acute  cases  were  given  one 
bath  daily  and  plenty  of  the  water  to 
drink.  In  a  month  two  were  cured ;  the 
third,  an  alcoholic,  had  to  be  returned 
to  medicinal  treatment.  The  chronic 
cases  were  given  two  baths  daily  and 
the  water  to  drink,  and  all  were  cured 
in  from  three  to  six  weeks.  The  springs 
contained  water  at  220°  F.  and  92°  F., 
with  a  large  percentage  of  sulphur. 
T.  H.  Weisenburg  (Phila.  Med.  Jour., 
March  14,  1903). 

Irrigation  of  the  bowel  is  both  ra- 
tional and  useful.  To  overcome  the  ex- 
treme irritability  of  the  rectum  in  the 
acute  cases  a  suppository  or  solution  (4 
per  cent.)  of  cocaine  should  be  intro- 
duced as  a  preliminary  measure.  The 
irrigation  is  made  ^ith  the  long  rectal 
tube,  the  patient  being  in  the  dorsal  po- 
sition, with  a  pillow  under  the  hips.  The 
substance  to  be  injected  is  water  at  100° 
alone  or  containing  some  astringent 
drug:   alum,  acetate  of  lead,  sulphate  of 


zinc  or  copper,  nitrate  of  silver,  or  tan- 
nin. Tannin,  in  0.5  per  cent,  solution, 
is  highly  recommended  by  Kartulis,  who 
also  uses  this  drug  in  combating  amoebic 
dysentery.  Osier  regards  nitrate  of  sil- 
ver as  the  best,  although  not  in  the  very 
acute  cases.  In  the  chronic  form  it  is, 
perhaps,  the  most  satisfactory  treatment. 
The  solution,  in  this  class  of  cases,  is  to 
be  made  20  to  30  grains  to  the  pint,  and, 
if  possible,  3  to  6  pints  of  fluid  are  in- 
jected. At  times  the  irrigation  causes 
much  pain  and  is  immediately  rejected. 

Iodized  starch  internally  tried  in  more 
than  a  hundred  cases,  giving  a  mixture 
of  equal  parts  of  iodized  starch,  oil  of 
cinnamon,  and  oil  of  fennel,  about  1 
grain  four  times  a  day.  At  the  same 
time  irrigations  with  a  solution  of  iodized 
starch  to  which  are  added  a  few  drops  of 
chloroform,  tincture  of  iodine,  and  oil  of 
cinnamon  given.  Kotschorowsky  (Se- 
maine  M6d.,  No.  C2,  '96). 

Two  severe  cases  in  which  1-pcr-cent. 
solutions  of  creolin  used,  with  excel- 
lent results,  in  severe  dysentery.  A  pint 
and  a  half  of  the  solution  was  used  night 
and  morning.  Creolin  is  worthy  of  an 
extended  trial  in  dysentery.  George 
Johnston  (Treatment,  June  24,  '97). 

Antipyrine  used  in  a  case  of  severe 
acute  dysentery,  by  rectal  injection  three 
times  a  day  of  a  solution  of  75  grains 
dissolved  in  'A  pint  of  water.  Sedative 
action  of  the  antipyrine  greatly  allevi- 
ated the  patient,  who  gained  strength 
and  soon  recovered.  Ardin-Delteil  (Bull. 
Gen.  de  Th6r.,  Jan.  30,  '98). 

Rectal  injection  of  pcnnanganat«  of 
potassium  in  the  strength  of  8  grains  to 
the  quart  effective.  Half  of  this  quantity 
is  given  at  a  dose,  and  is  allowed  to  re- 
main in  the  bowel  from  half  a  minute 
to  two  minutes.  The  water  is  cither  cold 
or  warm,  according  to  the  needs  of  the 
case.  If  large  quantities  of  mucus  are 
present,  an  injection  of  a  pint  of  water 
containing  30  grains  of  bicarbonate  of 
sodium  is  to  be  previously  used.  Gasti- 
nel  (Jour,  do  Mud.  de  Paris,  Nov.  19, 
•99). 
39 


610 


DYSEXTERY.    TEEATMEXT. 


Metbvlene-blue  as  a  parasiticide  aims 
at  the  pathogenic  cause;  as  analgesic, 
it  reduces  the  hyperexcitability  of  the 
large  intestine;  as  a  cholagogue,  it  has  a 
very  pronounced  cholagogic  effect.  It  is 
administered  in  warm  injections  of  a 
litre  or  of  half  a  litre  at  first  until  the 
intestine  becomes  tolerant,  containing  in 
solution  from  1  to  2  decigrammes  of  the 
drug.  Two  to  four  injections  are  given 
daily.  Berthier  (La  'M6d.  Moderne,  Oct. 
10,  1900). 

Inflation  of  the  rectum  with  carbonic- 
acid  gas  acts  at  once  by  ansesthetizing, 
relieving  the  tenesmus  which  character- 
izes dysentery,  and  stimulates  the  circu- 
lation, thereby  relieving  inflammation. 
It  is  a  more  effective  means  than  tJie 
well-known  aqueous  or  starchy  enema  ta. 
A.  Rose  (X.  Y.  Med.  Jour.,  July  14, 
1900). 

Powdered  cinnamon  an  excellent  reme- 
dial agent  in  all  cases  ranging  from  ordi- 
nary diarrhoea  to  severe  cases  of  dysen- 
tery. It  may  be  given  in  teaspoonful 
doses  mixed  with  a  little  milk  to  mold 
it  into  the  shape  of  a  bolus,  and  chewed 
night  and  morning.  A.  X.  Wilkinson 
(Brit.  Med.  Jour.,  Feb.  10,  1900). 

Ko-sam    (brueea   Sumatrana)    is   very 
useful  in  the  treatment  of  dysentery  of 
Cochin   China.     There   were  799   radical 
cures  after  a  period  of  from  three  to  si.x 
days.     Only  8   cases  resisted   the  treat- 
ment.   Ten  grains  are  given  the  first  day, 
12  grains  the  second,  third,  and  fourth,  if 
necessary.     The  active  principle  of  the 
plant  appears  to  be  quassine.     Mongeot 
(Tribune  Med.,  June,  1900). 
In  amoebic  dysentery- the  use  of  qui- 
nine irrigations  was  introduced  by  Losch, 
who  found  that  solutions  of  1  to  5000 
destroyed  the  organisms.     Stronger  so- 
lutions—! to  2500,  1  to  1000,  and  1  to 
500 — are  borne  well  and  may  be  injected 
three  or  four  times  a  day.    Corrosive  sub- 
limate in  solution  of  1  to  500  or  1  to 
3000,  and  nitrate  of  silver,  30  grains  to 
the  quart,  are  also  beneficial,  but  must 
be  used  more  cautiously.     11.  F.  Harris 
has  scon  benefit  result  from  the  use  of 
hydrogen  peroxide  in  some  cases.     The 


ordinary  commercial  hydrogen  peroxide 
is  diluted  from  four  to  eight  times  with 
water  and  about  a  quart  injected  twice 
daily.  The  treatment  is  continued  for 
one  week  and  then  the  quantity  gradu- 
ally diminished. 

Fifty-four  cases  treated  by  enemata  of 
corrosive  sublimate,  1  to  5000,  of  which 
6  ounces  were  injected  three  times  a  day; 
later  on  a  solution  of  1  to  3000  was  in- 
jected twice  daily.  The  fluid  was  not 
retained  usually  longer  than  ten  min- 
utes. Cases  cured  in  from  1  to  3  days. 
In  no  case  was  there  any  sign  of  systemic 
poisoning.  Lemoine  (Bull.  G6n.  de  Thfir., 
Jan.  30,  '90). 

In  dysentery  of  the  newborn  small 
doses  of  calomel,  flushing  the  colon  with 
a  weak  solution  of  creolin,  and  giving 
the  child  nothing  but  pure  cold  water 
prove  rapidly  eft'ective.  Gibson  (St. 
Louis  Med.  Era,  Sept.,  1900). 

In  Xatal  success  attended  the  use  of 
mercury  perchloride  in  mixture  with  bis- 
muth and  opium.     Milk  was  found  un- 
suitable.   Beef-tea  and  bread  with  butter 
satisfy,   and  leave   a   residue  which   ap- 
pears to  cause  but  little  colic  or  rectal 
irritation.        Post-mortem      observations 
show    that   great   risk   must   frequently 
accompany   the    giving   of   rectal    injec- 
tions,   especially    when    combined    with 
abdominal  massage.     The  co-existence  of 
enteric  fever  ■\\itli   dysentery   was  more 
than  once  unexpectedly  disclosed  in  the 
mortuary  tent.     W.   Watkins  Pitch toid 
(Brit.  Med.  Jour.,  Xov.  1,  1900). 
For  any  of  these  measures  to  be  effect- 
ive in  amoebic  cases,  they  must  be  con- 
tinued until  the  amoaboa  disappear.     In 
order  to  decide  this  an  intermission  of 
a  couple  of  days  is  made  in  the  treat- 
ment.   If  at  the  end  of  this  time  amoebre 
are  still  present  the  procedures  must  be 
renewed.    In  the  gangrenous  cases  little 
good  can  be  looked  for  from  the  injec- 
tions, and,  indeed,  they  are  not  without 
danger  of  precipitating  a  fatal  termina- 
tion by  causing  perforation  of  the  al- 
ready-much-injurcd  intestine. 

Wlien  tenesmus  is  slight  an  enema  of 


DYSENTERY. 


DYSMENORRHCEA. 


611 


thin  starch  containing  V2  to  1  drachm 
of  laudanum  affords  great  relief;  for  the 
more  severe  tormina  and  tenesmus  the 
hypodermic  injection  of  morphine  is  the 
only  satisfactory  remedy. 

Case  of  colostomy  for  the  cure  of  dys- 
entery. The  idea  of  the  operation  is: 
(1)  to  give  the  bowel  a  complete  rest 
by  not  allowing  the  fseeal  mass  to  pass 
ovpr  it,  and  (2)  irrigation  can  be  carried 
out  with  better  success.  Previous  to  the 
operation  the  patient  suffered  consider- 
able pain,  with  high  fever;  these  sub- 
sided two  days  after  the  operation,  and 
amoeba  eoli  also  disappeared.  W.  N. 
Sullivan  (Jour.  Amer.  Med.  Assoc,  Dec. 
8,  1900). 

During  the  period  of  convalescence 
tonics  containing  some  form  of  iron  and 
a  nourishing,  but  unirritating,  diet  are 
to  be  ordered.  The  recuperation  of  the 
patient's  strength  is  to  be  facilitated  by 
these  and  other  well-known  means. 

Method  of  obtaining  and  testing 
therapeutic  serum  for  use  in  dysentery. 
The  horse  or  ass  was  used  as  the  im- 
mune animal,  an  antiseptic  (carbolic 
acid)  was  added  to  the  serum,  and  the 
testing  was  carried  out  on  guinea-pigs 
and  mice.  The  author  has  treated  470 
cases  of  dysentery  since  1S97;  of  these, 
258  had  the  serum.  It  was  injected  into 
the  side  of  the  chest,  and  the  dose  varied 
from  C  to  10  cubic  centimetres  in  mild 
cases  to  15  to  20  cubic  centimetres  in 
serious  ones.  Usually  the  site  of  the 
injection  showed  no  change.  An  erup- 
tion around  the  site  occasionally  fol- 
lowed (37  per  cent.);  this  was  very 
rarely  found  all  over  the  body  (2.5  per 
cent.),  and  sometimes  there  was  pain  in 
the  joints  (knee,  elbow,  wrist).  If -the 
treatment  was  carried  out  in  the  early 
stages  of  the  disease,  the  diarrhoea  dis- 
appeared and  in  two  or  tliree  days  nor- 
mal stools  were  passed;  but,  if  it  was 
given  at  the  time  when  the  stools  were 
muco-sanguineous,  the  diarrhoea  was 
only  diminished,  and  the  duration  of  the 
illness  was  somewhat  shortened.  With 
the  serum  the  mortality  was  from  12.5 
to  8.5  per  cent.;    with  medicinal  treat- 


ment it  was  35.6  per  cent.  K.  Shiga 
(Brit.  Med.  Jour.,  from  Sei-i-Kwai  Med. 
Jour.,  June  30,  1001). 

SiiioN  Flexxer, 

Philadelphia. 

DYSMENOKKHCEA.  —  Gr.,  ^fj,  difR- 
cult;/r<-Ma(a,  menses;  SLjxd  pel r,  to  flow. 

Definition. — Dysmenorrhoea  is  not  a 
disease,  it  is  only  a  symptom.  The  term 
has  often  been  used  in  a  very  loose  way 
to  signify  any  or  all  the  painful  or  other 
disagreeable  sensations  which  may  be  as- 
sociated with  the  abnormal  performance 
of  the  function  of  menstruation.  The 
headaches,  the  pains  in  the  joints  and 
muscles,  the  backaches,  the  nausea  and 
vomiting  which  are  of  such  frequent 
occurrence  at  the  menstrual  epoch  do  not 
constitute  dysmenorrhoea,  though  they 
are  doubtless  influenced  by  the  same 
cause  which  produces  dysmenorrhcea. 
This  symptom  must  be  referred  to  the 
pelvic  organs,  to  their  nervous  system, 
and  to  their  vascular  sj'stem;  in  other 
wordSj  dysmenorrhoea  is  pain  in  the  pel- 
vic organs  which  is  experienced  in  con- 
nection with  the  function  of  menstrua- 
tion. It  is  a  sj'mptom  of  a  pathological 
condition.  A  woman  who  is  in'  perfect 
physical  condition  menstruates  without 
pain. 

Dysmenorrhcea  may,  therefore,  be  de- 
fined as  a  deviation  from  normal  men- 
struation, menstruation  meaning  essen- 
tially a  monthly  congestion  of  the  vascu- 
lar system  of  the  pelvis  in  obedience  to  a 
recurring  impulse,  with  the  shedding  of 
more  or  less  of  the  endometrium  and  the 
discharge  of  glandular  secretions,  the 
tension  of  the  vascular  system  being  re- 
lieved by  the  discharge  through  the  uter- 
ine canal  of  a  greater  or  smaller  quantity 
of  blood. 

S3nnptonis. — The  pain  of  dysraenor- 
rh(va  differs  as  to  the  time  of  its  occur- 


613 


DYSMENOKEHCEA.    SYMPTOMS. 


rence,  its  intensity,  its  duration,  and  the 
conditions  which  produce  it.  It  occurs 
most  frequently  during  the  day  or  the 
two  or  three  days  which  precede  the 
menstrual  flow. 

In  ovarian  dysmenorrhoea,  usually 
within  twenty-four  to  forty-eight  hours 
before  flow  appears  the  patient  is  seized 
with  sharp,  darting  pains  in  one  or  both 
ovarian  regions,  generally  the  left.  This 
pain  remains  constant  or  increases,  until 
finally  a  show  of  blood  takes  place.  The 
pain  is  not  in  the  median  line,  but  on 
either  side,  and  in  this  respect  the  pain 
differs  from  that  due  to  a  uterine  cause. 
Munde  (Med.  Brief,  May,  '96). 

Eeport  of  20  cases  of  intermenstrual 
dysmenorrhoea,  besides  25  collected  from 
literature.     The  pain  generally  occurred 
from  12  to  16  days  after  the  beginning  of 
the  previous  menstruation  and  continued 
from  2  to  4  days,  reached  its  maximum 
on  the  first  or  second  day,  was  often  dif- 
ferent in  character  from  the  menstrual 
pain,  and  was  rarely  accompanied  by  dis- 
charge.     Attributed    to    awakening    of 
menstrual  activity  for  the  coming  men- 
strual period.     Malcolm  Storer    (Boston 
Med.  and  Surg.  Jour.,  Apr.  19,  1900). 
With  many  women  the  beginning  of 
the  flow  means  the  relief  of  tension  and 
the  relief  also  of  pain;    with  others  it 
continues,  sometimes  diminishing,  some- 
times retaining  its  acuteness  until  the 
pelvic  congestion  has  subsided. 

There  are  two  conditions  present  in 
anteflexion  which  are  responsible  for  the 
pain.  One  is  the  swelling  of  the  uterine 
mucosa  which  accompanies  the  flow,  the 
other  the  condition  of  abnormal  sensi- 
tiveness at  the  internal  os.  The  tissues 
at  the  OS  internum  are  apt  to  be  more 
rigid  than  normal  and  the  nerves  in  an 
extremely-hypertesthetic  state.  The  in- 
creased congestion  which  accompanies 
the  onset  of  menstruation  and  the  ten- 
sion of  the  tissues  generally  irritate  the 
nerves  ond  aggravate  the  pain.  This  is 
tlie  case  during  the  first  few  hours  of 
the  flow.  Later  the  tissues  become  re- 
laxed, and  the  canal,  to  a  certain  extent, 
straightened,  and  the  pain  disappears. 
After   a   time   varying   from   twelve   to 


twenty-four  hours  relaxation  has  oc- 
curred, the  flow  is  more  profuse,  and  the 
pain  has  largely  ceased.  Davenport  (Bos- 
ton Med.  and  Surg.  Jour.,  June  2,  '98). 
In  intensity  it  may  be  a  simple  ache,  a 
feeling  of  distension  within  the  pelvis,  or 
it  may  be  an  acute,  continuous,  neuralgia- 
like sensation.  It  is  often  spasmodic  in 
character,  with  a  feeling  of  contraction 
or  bearing  down  in  the  uterus,  and  may 
be  relieved  when  a  clot  or  gush  of  blood 
is  ejected  froin  the  uterine  cavity.  The 
acuteness  of  the  pain  is  also  governed  by 
the  temperament  of  the  patient,  a  highly- 
organized  sensitive  person  suffering 
more  than  a  phlegmatic,  insensitive  one. 
It  is  more  frequently  experienced  in 
damp  than  in  dry  weather,  at  the  sea- 
shore rather  than  at  the  mountains,  dur- 
ing an  ocean-voyage  rather  than  on  a 
journey  inland.  The  more  scar-tissue 
there  is  in  and  around  the  uterus,  the 
greater  the  flexion  of  the  organ,  and  the 
narrower  the  cervical  canal,  usually  the 
more  constant  will  be  the  occurrence  of 
pain. 

The  customary  classifications  which 
can  be  verified  by  anyone  with  a  few 
years  of  practical  experience  are,  for  the 
most  part,  satisfactory,  but  the  writer  has 
adopted  the  following  as  the  results  of 
his  experience,  viz.: — 

1.  Dysmenorrhoea  from  congestion. 

2.  Dysmenorrhoea  from  obstruction. 

3.  Dysmenorrho3a  from  neuroses. 

4.  Dysmenorrhea  from  endometrial 
hypertrophy. 

1.  Dysmenorrhoea  from  congestion. 
This  is  the  simplest  of  all  the  varieties. 
Congestion  is  always  and  necessarily  a 
feature  of  menstruation;  that  is,  the  cur- 
rent in  the  pelvic  vessels  is  then  more 
rapid  or  the  tension  or  volume  is  greater, 
or  perhaps  all  these  elements  are  com- 
bined. When  the  degree  of  this  con- 
gestion is  greater  than  can  be  readily 
tolerated  by  the  person,  pain  is  one  of 


DYSMENORRHCEA.    SYilPTOMS. 


613 


its  results  (the  other  results  need  not 
concern  us  now),  and  this  pain  will  last 
as  long  as  the  congestion  continues,  and 
will  recur  as  frequently.  Tolerance  of 
this  condition  to  a  greater  or  lesser  ex- 
tent is  acquired  by  many  women,  just  as 
other  disagreeable  experiences  become 
tolerable  when  habitual  and  inevitable. 
In  some  cases  the  pain  seems  limited  to 
one  or  both  ovaries,  in  others  to  the 
uterus,  and  in  others  it  seems  to  be  dis- 
tributed through  the  pelvis. 

3.  Dysm.enorrhcea  from  obstruction. 
There  has  been  much  discussion  for 
many  years  concerning  this  variety,  some 
writers  going  as  far  as  to  say  that  the 
vascular  system  of  the  pelvis  was  so  ac- 
commodative that  dysmenorrhoea  from 
obstruction  was  not  possible.  Clinical 
facts  do  not  warrant  such  a  statement. 
Obstruction  of  the  outflow  of  blood  is, 
perhaps,  not  so  great  when  the  womb 
is  flexed  backward  or  forward  as  was 
claimed  a  few  years  ago  by  Sims,  Hewitt, 
and  others,  especially  if  coagulation  of 
the  blood  within  the  uterus  does  not  oc- 
cur; but,  if  such  coagulation  does  take 
place  (and  in  some  cases  also  in  which 
it  does  not),  d3'smenorrhcea  will  be  a  very 
pronounced  symptom. 

With  stenosis  of  the  cervical  canal  the 
same  difiiculty  to  the  outflow  of  the 
menstrual  product  is  also  frequently  ob- 
served. With  imperforation  of  the  hy- 
men or  of  the  os  internum  or  externum 
obstruction  to  outflow  is  complete.  A 
certain  portion  of  the  transuded  blood  is 
reabsorbed,  but  the  remainder  persists, 
distending  the  vagina  or  the  uterus  or 
botli,  sometimes  producing  a  very  large 
tumor,  and  invariably  resulting  in  great 
pain,  which  in  some  cases  has  led  to  a 
fatal  result. 

Pain  from  incomplete  development  of 
the  pelvic  organs,  especially  the  uterus. 
is  also  to  be  referred  to  obstructive  dvs- 


menorrhoea  as  its  origin,  and,  as  in  cer- 
tain cases  of  congestive  dysmenorrhoea, 
the  bad  symptoms  are  not  limited  to 
pain.  Dysmenorrhcea  from  inflamma- 
tory exudate  is  an  acquired  symptom,  the 
exudate  binding  the  pelvic  organs  into 
a  more  or  less  firm  mass,  which  tends  to 
become  firmer  as  the  contraction,  which 
time  brings  with  it,  takes  place.  The 
pain  in  such  cases  is  not  limited  to  ob- 
struction to  outflow;  indeed,  there  is  no 
such  obstruction  apparent  in  some  of  the 
cases,  the  flow  being  profuse  in  some  in- 
stances and  scanty  or  absent  in  others. 
The  remarks  concerning  inflammatory 
exudate  will  also  apply  to  scar-tissue, 
which,  by  its  presence,  will  often  effectu- 
ally obstruct  the  passage  of  the  menstrual 
blood-current.  To  this  variety  of  dys- 
menorrhoea might  also  be  added  those 
cases  which  are  so  often  seen  that  de- 
pend upon  perverted  or  imperfect  nutri- 
tion and  in  which  constipation  is  an 
ever-present  accompanying  symptom. 

3.  Dj'smenorrhoea  from  neuroses. 
There  may  be  at  least  two  types  of  this 
variety;  in  one  of  them  the  neurosis  is 
the  sole  discoverable  source  of  trouble, 
in  the  other  it  is  secondary  to  disease  of 
some  other  character  within  the  pelvis. 

Hysteria  is  at  the  foundation  of  many 
of  the  cases  of  the  first-mentioned  vari- 
ety, the  pain  connected  with  menstrua- 
ation  being,  to  a  great  extent,  simulated 
or  imagined. 

When  we  realize,  however,  the  inti- 
mate anatomical  relations  which  the  s}Tn- 
pathetic  nerves  of  the  pelvic  organs  bear 
to  the  nerves  and  ganglia  of  the  rest  of 
the  organs  of  the  body,  we  are  quite  pre- 
pared to  believe  that  painful  sensations 
in  those  organs  miglit  be  transmitted  to 
the  organs  of  the  pelvis.  So  far  as  I  know 
there  have  been  no  exact  investigations 
upon  this  subject.  The  referred  or  re- 
flected pains  from  the  pelvic  to  the  other 


6U 


DYSMEXORRHCEA.    ETIOLOGY  AND  PATHOLOGi. 


organs  have  been  much  discussed  and  a 
Tariety  of  conclusions  has  been  reached. 
The  neuroses  in  the  pelvis  or  pelvic 
organs  which  occasion  dysmenorrhoea 
may  constitute  a  use  of  language  which 
is  somewhat  misleading.  Of  course,  all 
pain  is  the  evidence  of  nerve-irritation  or 
a  neurosis.  The  form  which  is  here  to 
be  considered  is  that  in  which,  aside  from 
mere  congestion  or  obstruction  as  an  at- 
tendant of  the  menstrual  experience, 
there  is  a  direct  irritation  of  nerve-tissue 
which  is  not  apparent  apart  from  the 
menstrual  epoch.  Such,  for  example,  is 
the  case  when  the  unusual  pressure  due 
to  the  congestion  of  menstruation  is  ex- 
perienced by  the  sacral  nerves  as  they 
pass  through  the  pelvis,  the  tissues 
being  already  the  seat  of  inflammatory 
exudate.  The  tissues  are  squeezed  and 
contracted  by  this  exudate;  but  the 
addition  of  the  menstrual  congestion 
introduces  a  further  element  of  press- 
ure, which  causes  irritation  of  the  nerves 
which  are  infringed  upon,  and  pain  is 
experienced,  which  radiates  in  the  di- 
rection of  the  imprisoned  nerves.  This 
condition  is  not  infrequently  found  in 
insane  women;  it  is  probably  a  factor  in 
producing  insanity,  and  such  insanity 
cannot  be  expected  to  ameliorate  perma- 
nently until  the  source  of  trouble  is  re- 
moved. 

4.  Dysmenorrha?a  membranosa.  This 
is  a  somewhat  rare  form  of  dysmenor- 
rhoea, but  one  which  has  long  been  recog- 
nized, and  is  described  by  all  writers  of 
gyn.Tcological  treatises. 

Dysmenorrhoea  membranosa  is  due  to 
an  hypertrophied  condition  of  the  endo- 
metrial decidua;  that  is,  of  the  exfolia- 
tive portion  of  the  uterine  mucous  mem- 
brane which  is  shed  at  each  menstrual 
epoch.  This  membrane  varies  in  thick- 
ness and  density  in  extreme  instances, 
showing  a  perfect  cast  of  the  cavity  of 
the  uterus. 


Separation  of  the  membrane  from  its 
underlying  attachment  and  its  expulsion 
from  the  uterus  mean  an  unusual 
amount  of  uterine  work  and  severe  pain 
as  an  almost  constant  accompaniment. 
It  usually  occurs,  too,  in  women  whose 
nutrition  is  defective,  and  is  conse- 
quently a  matter  of  more  serious  impor- 
tance than  if  it  were  among  the  robust 
and  well  nourished.  It  is,  of  course,  a 
form  of  obstructive  dysmenorrhcea,  but 
its  peculiarities  are  so  marked  that  it  may 
be  well  to  continue  to  consider  it  a  dis- 
tinct variety. 

Etiology  and  Pathology. — Anything 
which  prevents  or  disturbs  the  eqiiilib- 
rium  of  the  normal  conditions  described 
will  cause  dj'smenorrhcea.  It  is  of  ex- 
ceedingly frequent  occurrence.  It  is  a 
matter  of  great  surprise  that  so  many 
women  should  present  this  symptom, 
which  appears  with  some  of  them  at  the 
advent  of  puberty  and  continues  with 
varying  intensity  imtil  the  termination 
of  menstrual  life,  while  with  others  it 
disappears  with  pregnancy,  with  the 
phj'sical  changes  attending  mature  life, 
or  as  the  result  of  surgical  treatment. 

That  it  should  occur  so  frequently,  and 
especially  in  communities  in  which  the 
highest  intellectual  development  has 
been  reached,  is  not  a  flattering  com- 
mentary upon  the  results  of  modern 
civilization.  Still,  this  is  counterbal- 
anced by  the  fact  that  dysmenorrhroa  is 
usually  curable  by  judicious  ineaus. 

A  tlioroiigli  revision  of  our  views  on 
tliis  subject  1ms  become  necessfiry  in  the 
light  of  recent  experience.  More  than 
".'5  per  cent,  of  the  cases  of  painful  men- 
struation are  not  dependent  upon  ana- 
tomical causes.  The  pain  is  really  due 
to  tetanic  contraction  of  the  circular 
muscle  at  the  os  internum,  such  as  oc- 
curs in  other  sphincter-muscles  in  neu- 
rotic subjects.  Menge's  theory  that 
dysmenorrhoea  is  due  simply  to  an  ex- 
aggeration of  the  contractions  of  the 
longitudinal   muscular   fibres,   which   al- 


DYSMENOREHCEA.    ETIOLOGY  AXD  PATHOLOGY. 


615 


ways  accompany  normal  menstruation, 
does  not  hold,  for,  if  the  symptoms  were 
due  purely  to  mechanical  obstruction,  it 
should  invariably  disappear  after  child- 
birth, which  is  not  the  case  in  nervous 
and  hysterical  women.  Uterine  colic 
cannot  be  due  only  to  the  passage  of 
dots,  since  in  many  typical  cases  of 
dj'smenorrhffia  there  is  a  free  escape 
of  fluid  blood.  Moreover,  the  pains 
are  often  most  severe  from  twelve  to 
twenty-four  hours  before  the  flow  ap- 
pears, instead  of  on  the  second  or  third 
day,  when  it  is  most  profuse  and  clots 
usually  appear.  Theilhaber  (Centralb. 
f.  Gyniik.,  No.  3,  1902). 

Dysmenonhoea  is  seemingly  on  the 
increase  and  is  developed  in  proportion 
to  the  strenuousness  of  the  human  exist- 
ence. The  period  of  p\ibcrty  should 
claim  the  attention  of  the  physician  as 
a  promising  field  for  preventive  gynoe- 
eology,  as  it  is  at  this  impressionable 
period  that  the  foundation  for  future 
suffering  is  laid.  It  is  the  duty  of  med- 
ical men  to  urge  the  necessity  of  propeily 
caring  for  the  physical  side  of  the 
schoolgirl,  not  permiitting  the  mental 
faculties  to  be  trained  at  the  expense  of 
the  physical  side. 

While  mindful  of  the  great  value  of 
surgery  in  the  treatment  of  certain  well- 
defined  pathological  conditions  in  the 
pelvis,  still  there  is  a  growing  tendencj- 
to  abuse  its  application  in  reference  to 
dysmenonhoea,  and  as  a  whole  the  re- 
sults obtained  through  its  intervention 
are  nothing  of  which  we  can  be  proud. 

A  more  careful  study  in  analysis  of 
these  cases  with  especial  reference  to  the 
etiological  facts  should  be  made,  with 
especial  reference  to  the  value  of  the 
application  of  the  general  hygienic  laws, 
electricity,  massage,  exercise,  etc.,  in 
contradistinction  to  the  reckless  and 
loose  surgical  measures  resorted  to  in 
their  treatment.  Dilatation  and  curet- 
ting is  of  value  in  well-defined  cases  but 
as  a  routine  procedure  is  wofully  abused. 
In  the  light  of  recent  experience  ob- 
structive dysmenorrha?a  is  rare,  and 
the  mechanical  side  of  dysmenorrhrra  is 
not  looked  upon  as  an  etiological  factor 
with  the  same  degree  of  frec|Ucnoy  now 
as  in  the  past. 


There  is  a  close  dual  relationship  ex- 
isting   between    the    generative    organs 
and  tlie  general  health,  and  in  the  treat- 
ment   of    dysmcnorrhtea,    it    should    be 
constantly  remembered.     S.  M.  D.  Clark 
(Xew    Orleans    Med.    and    Surg.    .Jour., 
Aug.,  l'J04). 
Women  in  the  savage  or  barbarous 
state  and  women  who  are  constantly  en- 
gaged in  out-of-door  labor  are  seldom 
sufferers  from  this  cause,  though  their 
pelvic  organs  may  be  defective  in  struct- 
ure and  though  they  may  habitually  be 
subject  to  experiences  which  would  un- 
failingly cause  dysmenorrhcea   or  even 
complete  suppression  of  the  menstrual 
function  in  women  of  less  robust  organ- 
ization.   This  is,  in  part,  owed  to  the  in- 
creased power  of  resistance  to  physical 
ills  which  is  favored  by  an  out-of-door 
life,  and,  in  part,  to  the  greater  insensi- 
tiveness  to  pain  of  women  in  the  lower 
strata  of  social  and  intellectual  develop- 
ment. 

"With  those  who  are  sufferers  the 
underlying  causes  are  various,  and 
demonstrate  the  important  role  which 
the  reproductive  organs  play,  not  alone 
in  the  propagation  of  species,  but  in  the 
experiences  of  daily  life. 

One  hundred  and  twelve  eases  of  dys- 
menorrhoea  examined.  One  of  the  most 
striking  points  is  the  very  large  num- 
ber of  sterile  women;  44,  or  a  fraction 
less  than  40  per  cent.,  belong  to  this 
class.  Of  those  who  had  been  pregnant, 
12  had  never  had  a  child  at  full  terra; 
15  more  had  had  a  miscarriage  since  the 
last  full-term  child  was  born,  leaving 
less  than  37  per  cent,  of  the  total  num- 
ber whose  last  pregnancy  had  come  to 
full  term.  These  figures  would  seem  to 
indicate  that,  in  a  large  proportion  of 
patients  suffering  from  dysmenorrhoea, 
there  were  present  lesions  which  also 
interfered  with  conception.  One  hun- 
dred out  of  the  112  suffering  from  pain- 
ful menstruation  were  found  to  have 
some  marked  organic  lesion  of  the  pelvic 
organs.  William  S.  Gardner  (Atlanta 
Med.  and  Surg.  Jour.,  Dec,  '0.5). 


616 


DYS3IEX0KRHCEA,    ETIOLOGY  AKD  PATHOLOGY. 


The  causes  may  be  classified  as  follows, 
■viz.:  heredity,  disease,  occupation,  and 
trauma. 

1.  Heredity.  "With  many  women  the 
defects  in  the  structiu'e  of  the  reproduct- 
ive organs  are  congenital  and  necessitate 
dysmenoirhoea. 

Inflammatory  diseases  of  the  ovaries 
and  the  Fallopian  tubes  and  adhesive  de- 
formities of  the  uterus  are  at  times  the 
causes  of  dysmenorrhoea.  In  100  of 
Kelly's  operations  on  tubes  and  ovaries 
the  appendix  was  found  adherent  in  21 
cases,  and  in  7  it  required  removal.  Out 
of  58  personal  cases  in  which  inflamma- 
tory appendages  had  to  be  removed,  the 
appendix  showed  enough  evidence  of  dis- 
ease to  justify  removal  in  20  cases.  In  9 
of  these  the  adhesions  between  the  ap- 
pendix and  the  right  appendage  were 
very  intimate.  A.  MaeLaren  (Amer. 
Gynsee.  and  Obstet.  Jour.,  July,  1900). 

It  does  not  avail  that  the  remainder 
of  the  physical  organization  is  normally 
developed;  indeed,  one  frequently  sees 
women  of  the  finest  physique  and  superb 
presence  whose  incomplete  pelvic  appa- 
ratus condemns  them  to  semi-invalidism 
during  a  considerable  portion  of  each 
month. 

On  the  other  hand,  puny,  delicate 
women  with  normally-developed  pelvic 
organs  suffer  with  dysmenorrhaaa  on  ac- 
count of  their  perverted  general  nutri- 
tion, their  flabby  muscular  system,  and 
their  low-ebb  vitality,  to  which  the  re- 
curring monthly  congestion  brings  a 
strain  which  they  are  ill  fitted  to  bear. 

The  defective  organization  may  in- 
clude any  portion  of  the  genital  appara- 
tus; in  the  vulva  it  may  take  the  form  of 
an  impermeable  hymen,  producing  an 
absolute  barrier  to  the  discharge  of  im- 
prisoned blood;  in  the  vagina  it  may 
consist  of  bands  and  septa  with  almost 
equal  obstruction  to  the  outflow  of  the 
monstnial  fluid;  in  the  uterus  it  may  be 


an  almost-impervious  cervical  canal,  an 
occluded  os  internum  or  externum,  less 
frequently  a  rudimentary  corpus  uteri  or 
one  with  its  two  halves  uncoalesced  or 
its  canal  obliterated;  in  the  tubes  or 
ovaries  the  structure  may  be  rudiment- 
ary or  the  seat  of  some  form  of  con- 
genital disease. 

Stenosis  may  be  due  to  swelling  of  the 
mucous  membrane  occurring  only  at  the 
time  of  menstruation,  and  consequently 
impossible  to  diagnose  at  other  times. 
Treub  (Centralb.  f.  Gyniik.,  July  17,  '97). 

Dysmenorrhea  should  be  divided  into 
dysmenon-hceal  endometritis  and  uterine 
spasm.  The  first  includes  all  forms  in 
which  there  is  any  local  mechanical  ob- 
stacle; all  other  cases  are  uterine  spasm, 
which  aflfects  the  sphincter  of  the  uterus, 
• — that  is,  the  cervix.  Of  1G7  patients 
observed,  37  complained  of  painful  men- 
struation. In  32  a  local  cause  was  dis- 
covered, but  in  the  5  others,  virgins, 
the  afi'ection  was  spasmodic.  Besides 
there  were  21  who  had  manifest  stenosis 
without  painful  menstruation.  Among 
these  subjected  to  curetting  there  were 
17  w-ith  dysmenorrhoea,  but  only  1  had 
marked  stenosis.  Of  these  last,  8  were 
completely  cured  by  curetting;  of  the  9 
others,  7  returned  with  a  relapse  of  their 
old  trouble,  and  2  received  absolutely  no 
relief.  De  Leon  (Centralb.  f.  Gynftk., 
July  17,  '97). 

Membranous  dysmenorrhoea  has  no 
connection  with  pregnancy  or  abortion, 
is  not  productive  of  sterility,  and  can 
become  cured  spontaneously.  The  fibri- 
nous membranes  are  to  be  regarded  as 
true  dysmenorrhojic  membranes,  and  are 
not  dependent  upon  an  indamniation  of 
the  uterine  mucosa.  Fibrinous  mem- 
branes are  the  product  of  necrosis  orig- 
inating in  hsemorrhagc  and  transudation. 
Kollmann  (Wiener  klin.  Rund.,  Apr.  29, 
1900). 

In  all  cases  thus  connected  with  he- 
redity, defective  organization,  etc.,  recur- 
ring monthly  congestion  produces  ten- 
sion   in    poorly-conditioned    structures. 


DYSMEXOREHCEA.    PROGNOSIS.    IREAT^IENT. 


617 


and,  if  the  tension  in  the  vessels  is  suffi- 
cient to  result  in  transudation  of  their 
contents,  the  outlet  being  imperfect  or 
wanting,  pain  will  be  the  inevitable 
result. 

2.  Disease.  Disease  of  one  kind  or  an- 
other may  cause  dysmenorrhoea,  whether 
the  disease  occurs  before  or  after  puberty. 
Before  puberty  there  are  many  forms  of 
disease  which  arrest  the  development  of 
the  pelvic  organs  and  result  in  dysmenor- 
rhcea.  The  exanthemata  seem  to  be  es- 
pecially productive  of  this  effect.  Why 
this  should  follow  has  not  been  satisfac- 
torily explained.  Measles,  scarlet  fever, 
small-pox,  all  have  their  victims  in  whom 
such  a  result  has  been  observed. 

Of  the  diseases  subsequent  to  puberty 
which  produce  dysmenorrhcea  there  are 
those  which  are  local  and  others  which 
are  general.  Of  the  former  may  be  men- 
tioned fibroid  tumors  either  within  the 
uterine  canal,  tn  its  muscular  substance, 
or  within  its  peritoneum,  and  inflamma- 
tory disease  of  the  tubes  of  the  ovaries 
or  of  the  pelvic  peritoneum.  All  these 
diseases  may,  by  their  obstructive  effect, 
prevent  free  discharge  of  blood  during 
the  menstrual  epoch,  and  produce  pain. 
Of  the  general  diseases  may  be  men- 
tioned typhoid  fever,  certain  diseases  of 
the  liver  and  gall-bladder,  ana?mia,  etc. 

The  same  result  is  often  seen  in  cases 
in  which  there  is  excessive  development 
of  fat.  Women  who  become  very  obese 
are  very  frequently  sufferers  from  dj's- 
menorrhcea. 

3.  Occupation.  Some  occupations  are 
especially  prone  to  result  in  dysmenor- 
rhcea. Those  who  work  in  a  very  hot  at- 
mosphere, like  cooks  and  laundresses; 
those  who  are  constantly  exposed  to  cold 
and  dampness,  like  fishwives  or  workers 
in  mines  (unwomanly  occupations); 
those  who  work  in  poisonous  substances, 
— copper,  arsenic,  lead,  phosphorus,  and 


sulphur;  those  who  are  confined  for 
long  hours  in  factories,  stores,  and  tene- 
ment-house "sweat-shops"  are,  in  many 
instances,  sufferers  with  dysmenorrhcea. 

4.  Trauma.  Dysmenorrhoja  from  this 
cause  is,  in  most  cases,  the  result  of  diffi- 
cult parturition,  the  genital  organs  sus- 
taining severe  injuries  and  cicatrization 
and  contraction  ensuing.  The  hardened 
tissues  are  anaemic  and  the  necessary 
elimination  of  blood  is  accomplished 
with  difficiilty  and  pain.  Occasionally 
there  are  direct  injuries  to  the  genital 
organs,  apart  from  parturition,  which 
also  produce  deterioration  of  the  tissues 
of  those  organs,  and  are  likewise  followed 
by  painful  menstruation. 

Prognosis. — The  prognosis  in  dys- 
menorrhcea varies  with  the  conditions 
and  varies  also  with  the  treatment.  If 
it  depends  upon  structural  defects,  and 
those  defects  are  remediable,  a  cure  will 
result.  It  sometimes  persists  during  the 
whole  menstrual  life,  but  with  many 
women  it  gradually  becomes  tolerable,  as 
all  ills  which  are  long  endured  become 
tolerable. 

With  regard  to  prognosis  much  will 
depend  upon  the  general  condition  of 
the  subject,  great  improvement  in  that 
direction  often  leading  to  menstruation, 
which  is  less  painful  or  not  painful  at  all. 
The  prognosis  in  cases  in  which  drug- 
treatment  alone  is  used  is  very  uncertain; 
while  such  treatment  is  proper  enough 
simply  as  a  means  of  relieving  or  be- 
numbing pain,  it  has  nothing  more  than 
a  temporary  and  palliative  effect  when 
the  pain  is  due  to  an  anatomical  fault  or 
defect. 

Treatment. — It  might  be  quite  appar- 
ent from  the  foregoing  that,  while  the 
treatment  may  be  either  medical  or  sur- 
gical, the  latter,  however,  will  usually 
give  the  more  satisfactory  and  radical 
results.     Jlodern  £rvncccolocrv  is  cast  in 


61S 


DYSMEXORKHCEA.    TREATMENT. 


surgical  lines,  and  while  it  would  be  folly 
to  deny  that  many  mistakes  have  been 
made  in  its  name  (for  mistakes  are  al- 
ways made  in  the  development  of  a  new 
department  of  knowledge),  it  has  ap- 
proached nearer  to  fundamental  condi- 
tions by  directly  attacking  tissues  which 
are  involved  in  disease  than  have  other 
methods  of  treatment  which  are  more 
circuitous  in  their  course. 

Considering  the  subject  of  treatment, 
therefore,  as  divisible  into  palliative  and 
radical,  the  former  will  include  the 
methods  by  means  of  drugs  (which  occa- 
sionally may  produce  a  permanent  re- 
sult), and  the  latter  (which  do  not  in- 
fallibly produce  a  cure)  those  methods 
which  involve  surgical  procedures.  Of 
course,  a  judicious  combination  of  both 
medical  and  surgical  means  will  often 
prove  efficacious. 

Of  the  drugs  which  may  be  given  to 
relieve  the  pain  of  menstruation,  mor- 
phine combined  with  atropine  should  be 
reserved  for  very  rare  cases  whether  given 
by  the  mouth  or  hypodermically.  It 
should  be  given  in  the  smallest  possible 
doses,  Vs  grain  sufficing  to  relieve  pain 
in  most  cases  as  well  as  a  larger  quantity. 
One  must  not  forget  the  seductive  influ- 
ence of  this  drug,  especially  upon  real 
nervous,  hysterical  women.  Many 
women  find  relief  from  the  pain  in  ques- 
tion by  drinking  hot  herb-teas:  chamo- 
mile, scutellarium,  boneset,  flaxseed,  etc. 
These  can  do  no  harm  and  arc  innocent 
as  to  the  formation  of  drug-habits. 

More  or  less  meritorious  preparations 
are  much  in  vogue,  but  in  some  cases 
they  seem  to  be  entirely  inert,  either 
from  instability  or  want  of  uniformity 
in  the  preparation  or  some  peculiarity  in 
the  patient. 

escalate  of  cerium,  in  0-grain  doses 
every  hour,  considered  speciflc  for  the 
dysnienorrhoea  of  well-nourished,  robust 
women,  in  cases  where  the  pain  eomes 


at  or  before  the  beginning  of  the  flow. 
Chambers  (Jled.  Record,  July  7,  'SS). 

Apiolin  is  especially  indicated  in  spas- 
modic and  congestive  dysmenorrhcea,  in 
doses  of  3  minims  in  capsules,  three 
times  a  day.  Hill  (Med.  Standard,  June, 
•91). 

In  non-inflammatory  cases  viburnum 
prunifolium  gives  brilliant  results,  not 
to  be  obtained  from  any  other  remedy 
except  morphine.  A  teaspoonful  of  the 
fluid  extract  three  times  daily  to  be 
given.  Sehwavtze  (Ther.  Gaz.,  Aug.  15, 
'94). 

Manganese  is  a  most  valuable  remedy 
in  unmarried  women,  and  a  trial  ex- 
tending over  three  months  is  recom- 
mended before  relinquishing  its  use.  Its 
action  appears  to  be  upon  the  neiTea 
or  nerve-centres  concerned  in  the  men- 
strual function  rather  than  upon  the 
blood.  Administration  of  manganese 
does  not  interfere  in  any  way  with  iron 
and  vegetable  tonics,  but  rather  en- 
hances their  efTeets.  Tlie  black  oxide 
is  tlie  most  convenient  form  of  prescrip- 
tion. If  nausea  is  produced  the  drug 
should  be  given  in  a  small  dose:  1  grain 
at  a  time  gradually  increased.  A  3-grain 
dose  is  found  to  be  as  efficacious  as  a 
larger  one.  Charles  O'Donovan  (Med. 
News,  Nov.  27,  '97). 

The  following  formula  has  given  good 
results: — 

R  Tincture  of  hydrastis  Canadensis, 
Tincture  of  viburnum  prunifolium, 
of  each,  equal  parts. 

M.  Ten  drops  to  be  taken  every  two 
hours.  Lutaud  (Jour,  de  MCd.  de  Paris, 
Jan.  2,  '98). 

Cases  in  which  the  flow  is  ushered  in 
by  severe  cramp-like  pains  for  three  or 
four  days  preceding  the  menstruation 
V:-drachm  doses  of  the  fluid  extract  of 
viburnum  prunifolium  in  hot  water 
three  times  a  day  may  bo  given,  and  on 
the  morning  of  the  expected  period  a  full 
dose  of  magnesium  sulphate.  If  the 
pain  comes  on  in  spite  of  this,  5-grain 
doses  of  antipyrine,  repeated  every  two 
hours  for  three  doses,  if  necessai-y,  will 
often  relieve  it.  Arthur  A.  Browne 
(Montreal  Med.  Jour.,  Apr.,  '98). 

In  dysmenorrhcea  thyroidin  is  "a 
uterine  and  ovarian  anodyne  and  seda- 


DYSMENORRHCEA.    TREATMENT. 


619 


tive,  as  it  arrests  the  different  impres- 
sions at  their  formation."    One  grain  of 
thyroidin    is    given    in    capsules    thrice 
daily,  for  two  days  before  menstruation 
is  due ;    the  quantity  is  increased  to  2 
grains  thrice  daily  during  the  flow.    Re- 
lief is  afforded  in  over  80  per  cent,  of 
eases.     The  treatment  is  efficient  when 
the  uterus  and   ovaries  are  in  normal 
position.    Any  pathological  lesion  must 
be   remedied   by    proper   surgical   meas- 
ures.    Stinson   (Amer.  Jour,  of  Obstet- 
rics, July,  1002). 
The    various    currents    of    electricity 
have  all  been  vaunted  as  useful  means  of 
treatment,  and  in  many  cases  they  are 
prompt  in  producing  relief.     Especially 
is  this  true  of  the  faradic  current,  but  if 
the  cause  of  the  trouble  lies  in  a  defect  of 
structure  it  would  be  unreasonable  to  ex- 
pect a  permanent  result  from  electrical 
treatment  so  long  as  the  cause  remains. 

Other  palliative  measures  are  warm 
hip-baths  in  which  the  patient  may  sit 
ten  to  fifteen  minutes,  the  temperature 
of  the  water  being  sufficient  to  produce 
relaxation  of  tissue,  and  hot  mustard- 
water  foot-baths,  which  must  be  used 
only  long  enough  to  produce  a  glow  of 
the  skin. 

Hot  salt-baths  calm  the  pains  of  dys- 
menorrhoea  and  notably  diminish  men- 
strual flow.  Mironoff  (Ejenedelnoya, 
No.  3.5,  '9.5). 

In  ovarian  dysmenorrhoea  all  remedies 
which  are  likely  to  relieve  pelvic  conges- 
tion  should  be  employed,   such  as  hot 
injections  and  sitz-baths,  hot-water  bags 
to  the  lower  part  of  the  abdomen,  and 
saline  laxatives.     Internal  medication  is 
of  very  little  avail.    In  cases,  however,  in 
which   menstruation  is  not  profuse  the 
mother-tincture   of   Pulsatilla   in   5-drop 
doses  every  three  hours  is  very  useful. 
:»Iunde  (Med.  Brief,  May,  '9G). 
With  mud-baths  and  the  medicated 
waters    of    Kreuznach,    Aix,    Toplitz, 
Schwalbach,  and  other  well-known  Euro- 
pean  resorts   useful   results  have   been 
obtained,  but  they  are  not  available  for 
the  majority  of  our  American  patients. 


A  change  of  residence,  especially  from 
the  sea-shore  or  near  the  sea-level  to  an 
elevation  of  one  or  two  thousand  feet, will 
often  give  permanent  relief.  The  writer 
has  repeatedly  seen  women  who  menstru- 
ate with  great  discomfort  at  the  sea- 
shore, while  on  sea-voyages,  or  in  a  damp 
atmosphere  imder  some  other  conditions. 
Of  course,  if  there  is  no  anatomical  lesion 
one  usually  becomes  habituated  to  at- 
mospheric conditions  after  a  few  months 
or  years. 

If  the  pain  is  due  to  a  neurosis  the 
treatment  should  be  addressed  to  the 
nervous  system, — the  bromides,  hyoscya- 
mus,  aconite,  and  the  coal-tar  prepara- 
tions being  employed. 

If  the  general  nutrition  is  at  fault  it  is 
hardly  necessary  to  say  that  it  should  be 
improved  by  a  carefully-selected  diet, 
suitable  exercise,  cheerful  companion- 
ship, and  alwaj's  and  above  all  by  the  use 
of  approved  laxatives  to  keep  the  bowels 
freely  open.  Again  and  again  has  the 
writer  found  a  constipated  habit  at  the 
bottom  of  a  history  of  painful  menstru- 
ation. 

The  majority  of  cases  of  dysmenorrhoea 
in  school-girls  is  functional  in  origin. 
Environment  should  be  such  as  would  be 
most  conducive  to  their  general  health. 
They  should  be  kept  out  of  school  dur- 
ing their  first  menstrual  year,  and  those 
of  a  nervous  temperament  for  a  longer 
period  of  time.  They  should  have  calis- 
thenic  training  for  the  special  develop- 
ment of  the  muscles  of  the  back  and  ab- 
domen, and  should  be  warmly  clothed. 
If  there  is  any  tendency  to  pain  during 
menstruation,  the  young  patient  shoiild 
be  put  to  bed  and  kept  there  the  entire 
period.  Pine  (Northwestern  Lancet, 
Dec.  1.5.  'Sni. 

The  field  of  surgical  treatment  for 
dysmenorrhcea  is  a  large  one  and  fre- 
quently will  result  in  the  happiest  conse- 
quences. The  chief  objects  of  surgical 
treatment  are  to  relieve  obstruction,  to 


620 


BYSMEXORKHCEA.    TREATMEKT. 


produce    stimiilation,    and    to    improve 
local  nutrition. 

The  causes  of  obstruction  have  been 
mentioned,  and  should  be  removed  as 
completely  as  possible;    an  imperforate 
hvmen  shoiild  be  divided  or  dissected 
away;    obstructing  bands  in  the  vagina 
should  be  cut  and  a  series  of  vaginal  dila- 
tors worn  until  the  normal  caliber  of  the 
vagina  has  been  restored.     Bands  and 
constrictions  at  the  os  externum  or  in- 
ternum should  be  divided,  a  narrow  cer- 
vical canal  should  be  dilated  and  cu- 
retted,, especially  when  the  glands  are  the 
seat  of  exuberant  or  unhealthy  secretion. 
[The  most  efficient  treatment  for  ordi- 
nai-y  forms  of  dysmenorrhoea  is  careful 
dilatation,  with  the  steel  dilator,  to  the 
extent  of  an  inch  or  an  inch  and  a  quar- 
ter, using  careful  antiseptic  precautions. 
After  the  dilatation  it  is  well  to  insert 
an    intra-uterine    pencil    containing    10 
grains  of  iodoform.    Munde  and  Wells, 
Assoc.  Eds.,  Annual,  '89.] 

Slow  dilatation  urged  as  being  equally 
effective  and  less  dangerous  than  rapid 
dilatation.  Talbot  (Araer.  Jour,  of 
Obstet.,  Jan.,  '89). 

Rapid  dilatation  for  the  relief  of  dys- 
menorrhoea depending  upon  flexion  or  ob- 
struction is  advocated,  in  the  absence  of 
contra-indications.  Goodell  (Amer.  Lan- 
cet, July,  '89) ;  Dickman  (Kansas  Med. 
Catalogue,  June,  '89) ;  Townsend  (Amer. 
Jour,  of  Obstet.,  Dec,  '89) ;  Madden 
(Satellite  of  the  Annual,  Sept.,  '89). 

Repeated  curettings  at  short  intervals 
advocated  for  membranous  dysmenor- 
rhoea. After  each  curetting  the  canal 
should  be  carefully  treated  to  an  applica- 
tion of  pure  carbolic  acid.  Reamy  (N. 
Y.  Med.  .Jour.,  June  10,  '93). 

For  membranous  dysmenorrhoea,  scari- 
fication of  the  OS  externum  at  intervals 
of  three  or  four  days  between  the  periods 
is  recommended.  Just  before  the  flow 
is  expected  the  cervix  is  dilated,  the  in- 
terior of  the  uterus  thoroughly  curetted, 
and  a  spiral-wire  stem  introduced;  this 
is  worn  continuously  during  at  least 
three  subsequent  periods,  the  patient  be- 
ing directed  to  take  hot  vaginal  douches 


even  when  menstruating.  Duke  (Med. 
Press  and  Circ,  July  10,  '95). 

Dysmenorrhoea  is  successfully  treated 
by  applications  to  the  mucous  membrane 
of  the  uterine  cavity.  The  treatment 
consists  in  the  injection  of  10  minims  of 
3-per-cent.  mixture  of  Churchill's  tinct- 
ure of  iodine  and  water  into  the  uterine 
cavity  every  four  or  five  days  during 
the  intermenstrual  period,  beginning 
about  five  days  after  the  flow  has 
ceased,  and  giving  the  last  treatment 
about  five  days  before  the  next  period 
begins.  As  an  injector  a  fine  glass  tube, 
curved  an  inch  from  one  end  and  ex- 
panded into  a  funnel  shape  at  the  other, 
is  used.  A  piece  of  sheet  rubber  covers 
this  end,  and  by  the  pressure  of  tlie 
finger  the  contents  are  passed  into  the 
uterine  cavity.  A  speculum  is  not  neces- 
sary, the  majority  of  eases  being  un- 
married. The  pain  and  exposure  made 
necessary  by  the  use  of  a  speculum  is 
objected  to.  Langstaff  (Brooklyn  Med. 
Jour.,  May,  '97). 

The  spasmodic  variety  is  by  far  the 
most  common,  as  there  is  frequently  lit- 
tle to  be  detected  beyond  the  symptom 
of  severe  spasmodic  pain.  Some  relief 
may  be  obtained  by  sedatives  externally 
or  internally,  but  there  is  always  the 
danger  of  setting  up  an  opium  or  chlo- 
ral habit;  it  is  better  to  dilate  the 
uterus,  either  by  tents  or  solid  instru- 
ments. The  use  of  tents  is  not  free 
from  danger,  both  from  sepsis  and  from 
fracture  or  tearing  away  of  a  piece  of 
the  tent  upon  extraction.  To  effect  rapid 
dilatation  the  solid  dilator  well  regu- 
lated is  to  be  chosen.  The  uterus  can 
be  easily  secured  by  the  vulsellum  for- 
ceps if  a  sound  is  previously  introduced 
into  the  cavity,  and  a  series  of  dilators 
can  then  be  passed  rapidly,  with  the  re- 
sult that  the  patient  is  relieved,  at  least 
for  many  months.  Murdoch  Cameron 
(Brit.  Med.  Jour.,  Oct.  24,  '97). 

In  sterile  married  women  prescription 
of  abstinence  from  marital  relations  for 
longer  or  sliorter  time,  followed  by  free 
dilatation  immediately  before  their  re- 
sumption, often  proves  successful  in  cur- 
ing dysmenorrhoea.  Bicycling  is  of  ad- 
vantage, and  if  growing  girls,  especially 
when   anicmic,   were   systematically   en- 


DYSMENORRHCEA.    TREATMENT. 


621 


couraged  to  practice  that  exercise  in 
moderation,  we  should  by  and  by  have 
less  spasmodic  dysmenorrhoea.  Connel 
(Brit.  Med.  Jour.,  Oct.  24,  '97). 

In  every  case,  without  e.xception,  gen- 
eral treatment  must  be  most  thoroughly 
tried  first.  At  the  time  of  puberty  many 
girls  get  far  too  little  e.xercise,  and  too 
little  care  is  taken  to  keep  them  warm, 
especially  at  night.  It  is  essential  that 
the  feet  be  kept  warm  during  the  night 
whenever  there  is  uterine  dysmenorrhcea, 
or,  indeed,  whenever  there  is  any  pelvic 
trouble.  As  soon  as  there  is  the  slightest 
appearance  of  the  "period"  the  girl  must 
be  kept  rigidly  in  bed,  and  not  allowed 
to  get  up  until  the  pain  is  entirely  gone. 
A  large  poultice  should  be  kept  over  the 
abdomen.  A  brisk  saline  draught  at  tlie 
commencement,  or,  if  possible,  twelve 
hours  before,  and  then  a  mild  diapho- 
retic, with  a  small  dose  of  bromide  of 
sodium  or  potassium,  if  the  patient  be 
strong,  or  if  weak  some  aromatic  spirit 
of  ammonia  are  best. 

In  regard  to  the  local  treatment  there 
is   more    or   less    difference    of   opinion. 
The  stem-pessary  is  unscientific;   it  can 
only  relieve,  seldom  cures,  and  may  do 
harm.    Dilatation  consists  of  two  kinds: 
slight  and  great.     The  first  is  suitable 
in  the  case  of  married  women,  when  flex- 
ion is  not  great,  and  it  is  used  in  the  hope 
that    by    distending    the    canal    impreg- 
nation may  take  place,  and  the  dysmen- 
orrhcea  thus   be  cured.     An   antesthetic 
is    not    required.      Overdilatation   may 
be  done  with  tents  or  the  rapid  forcible 
method.     Whatever  instrument  is  used 
in  the  rapid  method,  the  stretching  ought 
to    be   canied   out   while   the   uterus   is 
fixed  by  tenaculum  in  its  natural  posi- 
tion; not  when  it  is  drawn  to  or  out- 
side the  vulva.    Keith   (Med.  Press  and 
Circ,  Oct.  27,  '97). 
Obstruction    from    the    presence    of 
tumors  within   the   uterus  which   may 
cause  excessive  pain  can  be  relieved  only 
by  their  removal,  and  the  requisite  oper- 
ations must  also  be  performed  if  the  dys- 
menorrhcea is  caused  by  displacements  of 
the  uterus  or  its  incarceration  by  inflam- 
matory exudate.    Any  less  radical  form 
of  treatment  for  such  conditions  has,  in 


the  experience  of  the  writer,  proved  to  be 
only  time-consuming  and  futile. 

The  causes  of  dysmenorrhoea  may  be 
either  e.xtra-uterine  or  intra-uterine. 
The  treatment  differs  markedly  in  the 
two  classes  of  cases,  and  what  would 
relieve  in  one  would  be  worse  than  use- 
less in  the  other.  Three  factors  are  con- 
cerned in  the  production  of  the  pain  of 
dysmenorrhoea,  viz.:  contraction  of  the 
muscular  fibres  of  the  uterus  or  Fallo- 
pian tubes;  increased  spasm  or  blood- 
pressure  in  the  tissues  of  uterus  or  ap- 
pendages,— congestion;  neuralgia  of  the 
uterus  or  the  appendages.  The  cause  is 
to  be  treated.  Nearly  all  cases  are  bene- 
fited by  rest  at  the  periods,  hot  vaginal 
douches  during  and  between  the  periods, 
and,  in  inflammatory  cases,  tampons  of 
glycerin  and  ichthyol,  and  saline  aperi- 
ents. Morphine  and  alcohol  will  give 
great  relief,  but  must  never  be  recom- 
mended; the  administration  of  alcohol 
to  young  women  at  such  times  is  to  be 
blamed  for  much  of  the  secret  drinking 
that  prevails.  The  drugs  most  useful  are 
bromides  and  belladonna,  antipyrine  and 
cannabis  Indica,  and  both  viburnum 
prunifolium  and  viburnum  opulus.  Op- 
erative measures  should  only  be  resorted 
to  when  other  and  less  severe  remedies 
have  failed.  In  cases  due  to  spasmodic 
contraction  of  uterus  or  stenosis  of  cer- 
vix (if  there  be  no  signs  of  extra-uterine 
disease)  dilatation  is  often  of  some  serv- 
ice, but  is  seldom  of  more  than  tempo- 
rary benefit.  In  cases  due  to  chronic 
pelvic  peritonitis,  binding  down  and 
matting  together  the  uterus,  ovaries,  and 
tubes, — cases  in  which  the  ovaries  are 
cystic  and  the  tubes,  perhaps,  occluded 
and  the  uterus  retrovertcd  and  adherent 
to  the  rectum, — very  marked  and  per- 
manent benefit  results  from  a  "conserva- 
tive operation"  on  the  appendages.  The 
abdomen  should  be  opened,  the  uterus, 
ovaries,  and  tubes  freed  from  the  adhe- 
sions, and  after  ignipuncture  of  the  cys- 
tic or  sclerosed  ovaries  the  fundus  fixed 
to  anterior  abdominal  wall.  In  grave 
and  otherwise  incurable  lesions  of  the 
appendages,  such  as  abscesses  of  the 
ovary  or  pyosalpinx,  the  removal  of  the 
diseased  organ  is  strongly  indicated. 
Martin   (Brit.  Med.  Jour.,  Oct.  24,  '97). 


62-2 


DYSMEXOREHCEA. 


ECLAIIPSIA. 


The  use  of  pessaries  for  the  relief  of 
displacements,  while  it  frequently  modi- 
fies the  dysmenorrhoea,  seldom  cures  the 
displacements;  hence  such  means  are 
used  with  far  less  frequency  than  for- 
merly. The  same  may  be  said  of  the  cut- 
ting operations  -(vhich  were  once  so  popu- 
lar for  the  relief  of  dysmenorrhcea  sup- 
posed to  be  the  results  of  anteflexion  of 
the  uterus. 

Stimulation  of  the  uterus  and  im- 
provement of  its  nutrition  are  often 
effectively  produced  by  the  passage  of 


graduated  sounds  into  its  canal,  the  use 
of  the  steel  dilators,  curettage,  and  oc- 
casionally by  the  abstraction  of  blood 
from  the  cervix  with  leeches,  or  by  punct- 
ures or  scarification,  especially  when  the 
cervix  is  congested  and  the  menstrual 
flow  is  scanty. 

Andrew  F.  Currier, 

New  York. 

DYSPEPSIA.      See     Stojiach,     Dis- 
orders OF. 

DYSTOCIA.    See  Parturition. 


EAEACHE.  See  Middle  Ear,  Dis- 
eases OF. 

ECLAMPSIA.— Gr.,  ex?.a,u^(C,  a  shin- 
ing forth. 

Synonym. — Puerperal  convulsions. 

Definition. — Eclampsia  is  a  symptom- 
atic disorder  characterized  by  convulsive 
or  epileptiform  seizures  that  suddenly 
come  on  prior  to,  during,  or  after  labor. 

Symptoms. — The  physician  who  sys- 
tematically examines  the  urine  not  alone 
for  albumin  and  casts,  but  also  for  urea, 
and  who  keeps  check  of  the  amount  of 
urine  passed  in  the  twenty-four  hours  is 
not  likely  to  be  caught  napping  even  in 
those  cases  in  which,  although  there 
never  has  been  a  suspicion  of  renal  im- 
pairment, the  kidneys  are  nevertheless 
diseased.  Pari  passu  with  diminished 
excretion  of  urea  the  risk  of  toxnemia 
increases,  and  the  most  dangerous  form 
of  eclampsia — that  which  develops  sud- 
denly (without  much  premonition)  and 
passes  into  coma  and  death — frequently 
depends  on  urinary  insufTiciency  as  re- 
gards excretion. 

The  clinical  history  of  cases  of  the 
form  of  toxfcmia  under  consideration  is 


variable.  As  a  rule,  there  exists  a  pre- 
monitory symptomatology,  consisting  in 
cephalalgia  and  dimness  of  vision  or 
alteration  from  that  which  is  normal  in 
the  person. 

Instances  of  convulsions  during  preg- 
nancy observed  in  wliicli  every  fit  was 
regularly  preceded  by  transitory  amauro- 
sis, as  well  as  by  osdenia  of  the  face, 
which  was  also  of  short  duration.  Two 
sets  of  convulsions  occurred  during  preg- 
nancy: the  first  about  the  end  of  the 
seventh  month,  four  attacks  taking  place 
within  twenty-four  hours;  the  second 
in  the  course  of  the  eighth  month,  when 
two  fits  were  observed.  After  the  last 
convulsion  a  healthy  child  was  delivered. 
The  motlier  made  a  good  recovery.  The 
two  prominent  symptoms  above  men- 
tioned developed  before  each  of  the  six 
fits.  Olshausen  has  been  able  to  collect 
only  three  cases  of  eclampsia  in  which 
the  fit  was  preceded  by  an  aura,  as  was 
this  case.  Eabczewsky  (Przeglad  Chir- 
urgicuwy,  vol.  ii,  Pt.  3,  '95). 

Rarely  are  convulsions  unheralded.  In 
the  vast  majority  of  cases  thei-e  were 
prodromal  symptoms.  Frequent  urinary 
analyses,  both  qualitative  and  quantita- 
tive, should  be  made,  and,  if  albumin  is 
found  or  the  amount  of  the  solids  greatly 
diminished,  suspicion  should  be  aroused. 
Any  abnormal  symptoms — such  as  head- 
ache, disturbances  of  vision,  or  oedema — 


ECLAiU^SIA.     SYMPTOMS. 


623 


should  put  U3  on  our  guard.  WTien  such 
symptoms  appear  the  patient  must  be 
put  on  a  milk  diet  with  large  quantities 
of  sterilized  water;  hot  baths  employed, 
and  the  bowels  kept  active  by  catharsis 
and  saline  enemas.  The  continuance  of 
these  symptoms  demands  induced  labor. 
In  post-partum  eclampsia,  if  the  pa- 
tient is  plethoric  and  vigorous,  venesec- 
tion is  the  best  remedy;  if  anaemic  and 
weak,  veratrum,  accompanied  by  the 
transfusion  of  the  salt  solution,  is  indi- 
cated. H.  D.  Thomason  (Med.  Record, 
May  23,  '9C). 

Albumin  and  casts  may  or  may  not 
be  present  in  the  urine  according  to 
whether  a  nephritis  complicates  the 
pregnancy  or  not.  Should  the  premoni- 
tory symptoms  be  aggravated  elimina- 
tion of  urea  is  defective,  as  shown  by  the 
recognized  tests.  Insufficiency  on  the 
part  of  the  kidneys  may  be  determined 
by  measuring  the  amount  of  urine  passed 
in  the  twenty-four  hours.  Vascular  ten- 
sion is  apt  to  be  increased  except  in 
women  of  an  anfemic  type;  cedema,  as 
a  rule,  accompanies  organic  renal  dis- 
ease. 

The  symptomatology  of  the  eclamptic 
seizure  is  characteristic.  The  wide-open 
eyes,  fixed  in  vacant  stare:  the  contracted 
pupils,  the  rapidly  opening  and  closing 
lids,  the  clonic  convulsions.  These  sjTnp- 
toms  accompany,  ordinarily,  the  first 
seizures.  The  heart's  action  becomes  ir- 
regular, the  face  is  cyanosed,  the  breath- 
ing stertorous.  Soon  the  convulsions  be- 
come tonic  in  character;  the  eyes  are 
fixed;  opisthotonos  may  set  in. 

Much  importance  attached  to  severe 
frontal  or  unilateral  headache,  associated 
with  insomnia,  as  one  of  the  earliest 
symptoms  of  eclampsia.  F.  B.  Earle 
(Illus.  Med.  Jour.,,  Mar.,   1900). 

The  number  of  seizures  arq  variable, 
as  many  as  one  hundred  and  twenty-five 
in  the  twenty-four  hours  have  been 
noted.  The  duration  of  the  seizures  is 
from  about  thirty  seconds  to  a  minute, 


and  in  the  intervals  the  woman  is  con- 
scious; or  else  the  first  seizure  merges 
into  coma  and  ends  in  death.  Generally, 
after  delivery  of  the  fojtus  the  convul- 
sions cease.  Earely  eclampsia  develops 
after  delivery. 

In  the  course  of  four  and  a  half  years, 
among  44S0  cases  of  childbirth,  the  pro- 
portion of  cases  of  eclampsia  was  4.9  per 
thousand.  Of  the  44S0,  23S3  were  pri- 
niiparce  and  2097  multipara;  10  of  these 
cases  of  eclampsia  were  primiparae,  and  6 
multipara;  that  is,  equal  to  72.7  per 
cent,  of  primipartE  to  27.3  per  cent,  of 
multipara;.  Braun  found  the  percentage 
of  primiparffi  80.3;  Lijhlein,  85.4; 
Schauta,  82.0;  v.  Winckel,  70.8;  and 
Olshausen,  74  per  cent.  Women  attacked 
with  eclampsia  were,  for  the  most  part, 
young.  The  first  convulsive  seizure  oc- 
curred before  labor  in  2  cases,  during 
labor  in  15,  and  after  labor  in  5  cases. 
The  extent  of  the  discrepancy  as  to  ante- 
partum eclampsia  is  well  brought  out 
by  the  following  figuies:  Lohlein  gives 
4.7  per  cent.;  Strumpf,  7.4;  v.  Rosthoi-n, 
9.1;  Schauta,  14;  v.  Winckel,  23; 
Braun,  24;  and  Olshausen,  40  per  cent. 
The  convulsions  ended  at  the  termina- 
tion of  labor  in  8  of  the  22  cases.  The 
duration  of  the  convulsions  was,  on  the 
average,  one  minute.  The  severity  of  an 
eclamptic  seizure  is  only  to  be  meas- 
ured by  its  influence  on  the  respiration 
and  the  action  of  the  heart.  There  was 
albuminuria  in  the  whole  of  the  cases. 
Knapp  (Monats.  f.  Geburts.  u.  Gynilk., 
B.  3,  May  and  June,  '90). 

Xature  frequently  teaches  us  the  line 
of  action — spontaneous  abortion  occur- 
ring and  the  eclampsia  ceasing. 

Inasmuch  as  convulsive  attacks  may 
persist  after  delivery,  or  even  in  rare 
cases  may  appear  for  the  first  time  after 
delivery  is  completed,  the  plan  of  hurry- 
ing on  labor  with  the  object  of  checking 
the  attacks  must  necessarily  be  often 
completely  incflK-acious.  We  may,  there- 
fore, conclude  that  it  is  not  in  the 
evacuation  of  the  uterus  that  the  cure 
for  eclampsia  is  to  be  sought.  The  toxic 
condition  of  the  blood  dominates  every- 
thing else,  and  it  is  on  the  degree  of 


624 


ECLAMPSIA.    ETIOLOGY  AND  PATHOLOGY. 


toxicity,  which  is  so  difficult  to  de- 
termine, that  the  prognosis  of  the  disease 
depends.  Maygrier  (Jour,  de  Mfd.  de 
Paris,  Aug.  S,  '97). 

The  victims  of  nephritis  who  become 
pregnant  rarely  go  to  term,  but  abort  a 
dead  fcetus,  the  result  of  interstitial  alter- 
ations in  the  placenta. 

Etiology  and  Pathology. — Modem  be- 
lief teaches  that  eclampsia  is  the  result 
of  a  toxaemia.  The  acceptance  of  this 
broad  term  has  done  much  toward  the 
adoption  of  a  rational  method  of  treat- 
ment. The  definitions  which  for  long 
prevailed  in  medical  literature  simply 
complicated  the  topic.  Thus  the  view 
that  eclampsia  depended  on  pressure 
of  the  gravid  uterus  on  the  renal  ves- 
sels, while  negated  by  the  fact  that 
such  pressure  exercised  by  ovarian  and 
fibroid  growths  was  unaccompanied  by 
eclampsia,  and,  further,  that  the  gravid 
uterus,  when  risen  above  the  pelvic  brim, 
exerted  no  such  mechanical  interfer- 
ence with  the  kidneys,  led  the  mind 
of  the  observer  far  astray  from  a  strong 
presumptive  etiological  factor,  which  is 
deficient  excretion  of  toxic  products  em- 
anating not  alone  from  the  kidneys,  but 
also  from  the  liver. 

The  eclampsia  symptom-complex  is  de- 
pendent on  a  peculiar  irritation  change 
in  the  psychomotor  centres  of  the  cere- 
bral cortex  (subcortical  centres).  This 
zone  develops  during  gestation  on  an 
existing  disposition,  which  may  be  either 
congenital  or  acquired.  Herd  (MUn- 
chener  med.  Woch.,  No.  5,  '91). 

Puerperal  eclampsia  originates  from  a 
renal  insufficiency  causing  a  high  arterial 
pressure,  this  again  reacting  on  the  mo- 
tor areas  of  the  brain,  producing  the 
characteristic  epileptiform  manifesta- 
tions in  the  parts  of  the  body  presided 
over  by  the  centres  which  are  subject  to 
the  abnormal  blood-pressure.  R.  Max- 
well-Trotter (Brit.  Med.  Jour.,  May  9, 
'DO). 

Though  the  pathogenesis  of  eclampsia 
is  unsettled,  it  belongs  solely  to  the  preg- 


nant or  puerperal  state.  It  is  not  apo- 
plectic, epileptic,  or  hysterical  in  char- 
acter. It  depends  upon  toxtemia  due  to 
overproduction  of  toxins  and  under- 
elimination  by  the  emunctories.  These 
toxins  probably  have  their  origin  in  the 
ingesta,  in  intestinal  putrefaction,  in 
foetal  metabolism — one  or  all — and  there 
is  co-existing  sluggishness,  impairment, 
or  suspension  of  elimination.  When  the 
prodromes  of  eclampsia  appear,  the  kid- 
ney should  be  interrogated  as  to  its 
functions  and  all  symptoms  carefully 
watched.  W.  W.  Potter  (Amer.  Jour. 
Obst.,  Nov.,  '97). 

The  cause  of  pregnancy-kidney  is  prob- 
ably an  autointoxication  of  the  organism 
by  a  product  of  metabolism  during  preg- 
nancy. The  overloading  of  the  organism 
with  this  virus  gives  rise  to  eclampsia. 
The  changes  which  occur  in  the  kidneys, 
liver,  and  other  organs  in  the  eclamptic 
are  of  a  secondary  character.  Saft 
(Archiv  f.  Gynak.,  vol.  li,  p.  2). 

While  the  urine  of  healthy  pregnant 
women  has  been  reported  as  sterile, 
germs  may  be  cultivated  from  it:  the 
same  organisms  obtained  from  the  urine 
of  eclampsias.  These  urines  are  but 
feebly  toxic  when  injected  subcutane- 
ously  in  massive  doses  into  animals. 
Bar  (Obstetrics,  Jan.,  '99). 

The  bulk  of  evidence  is  distinctly  in 
favor  of  the  belief  that  a  profound  tox- 
femia,  originating  in  the  bodies  of  the 
mother  and  foetus,  causes  eclampsia.  The 
exact  agent  has  not  been  isolated.  An 
excessive  amount  of  serum-albumin  in 
the  urine,  accompanied  with  kidney  d6- 
hri-s;  is  a  symptom  of  moment.  The 
amount  of  urea  excreted  is  a  valuable 
index.  A  diminution  in  its  amount  in- 
dicates a  retention  of  toxins.  Jaundice 
is  an  especially  grave  symptom,  and, 
lifEmatogcnic  in  origin  in  these  eases, 
points  to  a  grave  toxreniia.  E.  P.  Davis 
(Amcr.  Gyntec.  and  Obstet.  Jour.,  July, 
'99). 

Study  of  59  cases  of  eclampsia  in  the 
Imperial  Maternity  at  Kieff.  Eclampsia 
shown  to  be  a  primary  disease  of  the 
kidneys  due  solely  to  nutoinfection  of 
the  patient  by  the  accumulation  of 
waste-products  in  the  maternal  and  fcetal 
blood.    It  is  essentially  a  disease  of  prcg- 


ECLAJIPSIA.    ETIOLOGY  AND  PATHOLOGY. 


625 


nancy,  not  of  parturition,  and  it  always 
tends  to  interrupt  gestation.  Abuladse 
(Monats.  f.  Geburts.  u.  Gyn.,  Sept.,  '99). 

Case  of  eclampsia  complicated  by  a 
marked  erythema  multiforme  of  a  bul- 
lous character.  Kaposi  ascribes  ery- 
thema multiforme  to:  (o)  Change  of 
seasons,  {b)  Angioneuroses  which  occur 
principally  in  women,  (c)  Instability  of 
the  vasomotor  centres,  (d)  Autoinfec- 
tion:  i.e.,  to.\ic  substances  which  have 
entered  the  blood  as  the  result  of  some 
internal  disease,  as  chronic  nephritis. 
The  case  cited  probably  comes  under  the 
last  division.  J.  D.  Voorhees  (Jled. 
Record,  Oct.  7,  '99). 

In  the  Boston  Lying-in  Hospital  dur- 
ing the  last  fifteen  years  90  cases  have 
occurred,  although  in  11  no  convulsions 
appeared.  There  were  79  cases  of  true 
eclampsia  in  G700  deliveries:  an  aver- 
age of  11.7  to  the  thousand.  Of  these, 
57,  or  72.2  per  cent.,  were  primiparre,  and 
22,  or  27.8  per  cent,  were  multiparse. 
Newell  (Boston  Med.  and  Surg.  Jour., 
Nov.  9,  '99). 

There  is  no  uniform  causal  factor  for 
puerperal  eclampsia.  Even  slightly  toxic 
products  in  the  blood  of  women  in  child- 
bed are  sufficient  to  irritate  the  vaso- 
motor centres,  which  are  then  in  a  con- 
dition of  increased  excitability.  E.  Herz 
(Wiener  med.  Woch.,  Nos.  3,  7,  8,  1900). 

Case  in  which  the  rapidity  of  death 
after  the  fits  suggested  cerebral  haemor- 
rhage. Free  haemorrhage  was  discovered 
on  the  surface  of  the  convolutions  of  the 
left  hemisphere  and  widel)'  distributed 
hosmorrhages  in  the  liver:  subscapular, 
interlobular,  and  intralobular.  Case  in 
which  sudden  and  rapidly  fatal  asphyxia 
was  caused  by  cerebral  htemorrhage, 
which  nearly  destroyed  the  bulb  and  the 
floor  of  the  fourth  ventricle.  Boissard 
(Bull,  de  la  Soc.  d'Obstet.  de  Paris,  Feb. 
15,  1900). 

The  etiology  of  puerperal  eclampsia  is 
still  a  mooted  question.  The  bacteria 
which  were  supposed  to  be  the  germs 
causing  eclampsia  are  found  in  all  preg- 
nant women.  When  the  blood  of  the 
eclamptic  patient  is  examined,  micro- 
organisms are  rarely  found,  and  from 
observations   one   can   find   no   positive 


proof  that  any  one  germ  has  been  iso- 
lated which  will  cause  eclampsia.  The 
universal  opinion  at  present  ia  that 
eclampsia  is  due  to  a  profound  toxoemia, 
and  tlie  origin  of  this  toxaemia  is  still 
unknown.  Beattie  (Jour.  Amer.  Med. 
Assoc,  Aug.  24,  1901). 

The  toxic  theory  of  eclampsia  is  now 
the  one  generally  held  by  most  obste- 
tricians, and  in  this  connection  the  fol- 
lowing points  may  be  mentioned:  1. 
That  in  every  case  of  pregnancy  more  or 
less  toxaemia  exists,  and  that  the  blood 
intoxication  becomes  more  profound 
toward  the  end  of  gestation.  2.  That, 
although  the  eclamptic  state  is  due  to  a 
toxaemia,  the  toxic  agent  which  excites 
the  convulsions  is  probably  not  always 
the  same;  there  seems  to  be  different 
types  of  the  disease.  3.  That  the  toxins 
may  be  produced  in  greater  abundance 
in  some  cases  (twin  pregnancies),  and 
that  they  are  generally  more  virulent  in 
primiparte  than  in  multipara;.  In  the 
primipara  mechanical  pressure  on  the 
renal  vessels  may  possibly  come  more 
into  play,  while  in  the  multipara  a  cer- 
tain degree  of  immunity  against  the 
toxin  may  have  been  acquired  from 
previous  pregnancies  (Allbutt).  4.  That 
in  spite  of  very  grave  toxtemia  no 
alarming  symptoms  will  occur  so  long 
as  elimination  by  the  kidneys  is  suffi- 
ciently active.  Of  the  nature  of  the 
toxins  nothing  is  known,  and  there  is 
no  clear  evidence  to  show  where  they 
are  formed. 

Lange  noted  that,  out  of  25  pregnan- 
cies in  which  the  usual  hypertrophy  of 
the  thyroid  did  not  occur,  albuminuria 
occurred  in  20.  Large  doses  of  thy- 
roidin  were  administered  to  pregnant 
women  in  whom  the  physiological  en- 
largement of  the  gland  had  occurred, 
and  a  marked  diminvition  in  the  size  of 
the  gland  resulted.  One  might  therefore 
conclude  that  the  normal  hypertrophy 
of  the  thyroid  gland  in  pregnancy  is  the 
result  of  a  demand  for  extra  secretion 
to  meet  the  wants  of  increased  metab- 
olism. With  a  continuous  supply  of 
artificial  secretion  the  gland  was  re- 
lieved of  the  additional  strain  and  re- 
sumed its  former  size.    Hallion  observed 


626 


ECLAilPSlA.    ETIOLOGY  A^'D  PATHOLOGY. 


similar  effects.    H.  0.  Xieholson  (Lancet, 
June  29,  1901). 

Of  all  the  theories  advanced  as  to  the 
cause  of  eclampsia  and  the  pre-eclamptic 
state,  none  have  appealed  to  us  as 
strongly  as  that  which  takes  into  con- 
sideration urinary  inadequacy,  with  the 
attendant  diminution  of  the  secretion 
of  the  solid  elements  of  the  \irine.  In 
other  words,  with  an  ever-increasing 
experience,  we  feel  as  morally  sure  as 
clinical  experience  will  allow  us  that 
this  dire  condition  is  due  to  the  poison- 
ing of  the  system  by  urea  or  one  of  its 
congeners.  S.  Marx  (Med.  Examiner 
and  Pract.,  March,  1903). 

The   idea    that  it   is   a   renal   disease 
seems  to  be  abandoned,  and  it  is  now 
generally  attributed  to   the  circulation 
of  poisons  in  the  blood,  either  from  the 
alimentary  canal  or  due  to  metabolism 
in  the  body   of  the   mother   or   of   the 
foetus,  or  of  both.     In  health  such  poi- 
sons are  either  at  once  expelled  from 
the  body  or  rendered  innocuous  by  its 
natural    organs    of    defense,— the    liver, 
kidneys,    thyroid,    and    other    glands,— 
but  a  breakdown  of  any  one   of  these 
throws    the    whole    mechanism    out    of 
gear.    In  most  pregnant  women  the  de- 
fensive power  proves  adequate ;  in  some, 
though  there  is  disturbance  of  function 
in  early  months,  adjustment  results  and 
the  symptoms  of  intoxication  pass  off; 
in  a  few  the  poisons  accumulate,  and 
eclampsia     or     other    serious    troubles 
result.      Fothergill    (Practitioner,    Feb., 
1903). 
As  in  the  course  of  more  extended 
knowledge,    the    etiological    factor    of 
eclampsia  was  recognized  as  being  asso- 
ciated with  hydramia  of  the  blood  and 
with  toxemia,  not  alone  has  the  pressure 
theory  been  exploded,  but  so  also  have 
the  vague  and  insuPTiciont  terms  uraimia 
and  urincemia  been  discountenanced  by 
the  modern  writer,  teacher,  and  practi- 
tioner. 

During  pregnancy  the  blood  alters 
both  in  (juantity  and  quality.  There  is 
an  increase  in  the  white  cells  and  a  de- 
crease in  the  red.    Albumin  and  iron  fall 


below  the  normal.     The  blood  becomes 

more  water}',  so  to  speak. 

Careful  histological  studies  made  of 
the  various  organs  in  a  large  number 
of  cases  of  puerperal  eclampsia.  In  the 
vessels  were  found  large  multinucleated 
cells,  which  were  considered  to  be  cells 
derived  from  the  placenta,  and  also 
multiple  capillary  thrombosis.  From 
these  facts  the  conclusion  drawn  that 
the  disease  is  essentially  due  to  the  pres- 
ence in  the  blood  of  a  coagulating  fer- 
ment formed  either  by  the  degeneration 
of  the  free  placental  cells  found  in  the 
blood  or  by  degenerative  changes  in  the 
placenta  itself.  Schmorl  (Virohow'a 
Archiv;  St.  Louis  Med.  and  Surg.  Jour., 
May,  '96). 

Chamberlent,  working  under  the  direc- 
tion of  Tarnier,  in  1892  performed  a 
series  of  experiments  on  the  blood  of 
eclamptic  women  and  published  the  fol- 
lowing conclusions: — 

1.  Pregnancy  tends  to  the  retention  of 
poisons  in  the  body,  for  the  urine  of  the 
pregnant  woman  is  less  poisonous  than 
normal.        , 

2.  In  eclampsia  the  elimination  of 
physiological  poisons  is  hindered,  and  the 
urine  is  less  poisonous  than  normal.  It 
is  also  less  poisonous  than  the  urine  of 
normally  pregnant  women. 

3.  The  blood-serum  of  the  eclamptic 
is  considerably  more  poisonous  than  nor- 
mal, and  its  toxicity  is  in  direct  pro- 
portion to  that  of  the  urine. 

The  poison  is  by  some  believed  to  have 
its  origin  in  the  fojtus  and  placenta;  but 
the  commonly-accepted  view  is  that  the 
poison  is  of  maternal  origin  from  im- 
paired metabolism,  together  witli  reten- 
tion from  impaired  cliiiiinative  capacity 
of  the  kidneys. 

The  albuminuria  of  eclampsia  is  prob- 
ably secondary,  following  the  direct  ac- 
tion of  the  poison  on  the  renal  epithelial 
colls,  in  tlie  effort  at  elimination.  Its 
almost  universal  presence  in  the  eclamp- 
tic renders  it  a  sign  of  some  importance. 
Only  about  one-eighth  of  eclamptics  sub- 
scqiicntly  develop  nephritis,  the  albumin 
disappearing  from  the  urine  in  from  a 
few  weeks  to  a  few  months  after  the 
attack,  depending  largely  on  the  hygienic 
conditions  which   surround  the  patient. 


ECLAMPSIA.     PROGNOSIS. 


627 


While  a  patient  with  nephritis  may  and 
does  sometimes  have  eclampsia,  it  is  by 
no  means  the  invariable  rule.  J.  L. 
Rothrock  (Northwestern  Lancet,  Nov. 
15,  '97). 

That  the  blood-serum  of  eclamptics  is 
more  toxic  than  normal  cannot  be 
proved;  but,  on  the  contrary,  the  blood- 
serum  of  eclamptics  produces,  when  in- 
jected into  animals,  the  same  symptoms 
caused  by  normal  serum. 

Both  blood-serums  produce  dissolution 
of  blood-corpuscles  and  hemoglobinuria; 
both  affect  most  powerfully  when  in- 
jected continuously.  Volhard  (Monats. 
f.  Geburts.  u.  Gynilk.,  B.  5,  H.  5,  '97). 

Certain  substances  injected  directly 
into  the  foetus  or  the  amnion  are 
rapidly  absorbed  by  the  maternal  or- 
ganism, provided  the  foetus  is  living,  but 
much  more  rapidly  from  the  fojtus  than 
from  the  amnion.  From  this  it  would 
seem  that  the  foetus  secretes  certain 
toxic  substances  into  the  blood  and  am- 
niotic fluid.  Secondly,  if  the  foetus  be 
dead,  substances  injected  into  either  am- 
nion or  fcetus  do  not  seem  to  pass  into 
the  maternal  circulation.  This  would 
seem  to  throw  considerable  light  upon 
the  various  phenomena  of  eclampsia,  and 
especially  as  showing  that  the  death  of 
the  fcetus  is  followed  by  cessation  of  the 
convulsive  seizure.  Baron  and  Castaigne 
(Arch,  de  Med.  Exp6rimcntale,  Sept., 
'98). 

A  large  coccus,  round  or  oval  in  shape, 
and  of  remarkable   individual   mobility, 
believed   to   have   a    definite   connection 
with  the  etiologj'  of  the  disease.    Found 
in    the    blood    of    forty-four    eclamptics. 
Lewinowitsch    (Centralb.  f.  Gyniik.,  No. 
46,  '99). 
The    systemic    cell-activity    in    the 
pregnant   woman   is   greatly   increased. 
Excrementitious    material    accumulates 
rapidly  in  the  sj'stem,  and  at  any  time 
the  balance  between  secretion  and  ex- 
cretion  may   become   disturbed    and   a 
toxaemia  or  poisoning  ensue.     If  this  is 
apt  to  occur  in  a  woman  conceiving  with 
normal  or  healthy  excretory  organs,  all 
the  more  so  is  it  likely  to  supervene  in 
a  woman  who  conceives  in  the  presence 


of  an  organic  disease  of  one  or  another 
of  the  excretory  organs — especially  the 
kidneys.  Thus  then  we  may  witness 
eclampsia  develop  during  the  pregnancy 
of  a  woman  with  kidneys  diseased  from 
the  start  or  in  women  in  whom  possibly 
there  has  never  been  a  suspicion  of  renal 
impairment. 

Eclampsia  is  not  common   in   women 
the   subjects   of  chronic   kidney   disease 
before  pregnancy;    where   kidney   symp- 
toms are  present  they  usually  develop 
suddenly;     kidney-lesions    may    be    ab- 
sent; albuminuria  is  in  many  cases  the 
effect  and  not  the  cause.     The  kidneys 
are  not  the  only  excretory  organs  whose 
failure  to  perform  elimination  properly 
may  produce  eclampsia.     Ptomaine  poi- 
soning should  not  be  forgotten.     J.  P. 
Boyd   (Albany  Med.  Annals,  Nov.,  '95). 
Prognosis. — The  prognosis  in  modern 
times  has  been  greatly  altered  for  the 
better.     AVhereas  formerly  the  maternal 
mortality  ranged  about  30  per  cent.,  now- 
adays there  are  series  of  cases  recorded 
with  as  low  a  rate  as  5  per  cent.    Some 
observers  in  a  limited  number  of  cases 
report  no  deaths.     The  foetal  mortality 
remains  about  50  per  cent. 

In  52,328  oases  of  labor  occurring 
within  a  period  of  2  years  there  were 
325  convulsions.  The  mortality  was 
19.38  per  cent.  Among  248  patients  who 
survived  the  attacks,  54  subsequently 
developed  other  conditions;  in  13  there 
were  psychoses,  generally  ending  in  re- 
covery; in  5  pneumonia,  3  pleurisy,  and 
in  22  kidney  trouble  persisted.  In  71.1 
per  cent,  operative  interference  became 
necessary,  including  108  forceps  deliv- 
eries. 19  versions,  13  operations  to  lessen 
the  size  of  the  child,  2  induced  abortions, 
and  7  Cesarean  sections.  Liihlcin  (Wi- 
ener mcdizin.  Woch.,  Sept.  19,  "91). 

It  the  amount  of  urea  in  the  blood  is 
twice  the  normal,  recovery  is  probable, 
while  if  it  very  nearly  approach  the 
physiological  proportion  the  termination 
is  generally  fatal.  This  is  also  the  case 
wlicn  the  amount  of  the  urea  is  five  or 
six  times  the  normal.  More  importance 
should  be  attached  to  the  hepatic  than 


628 


ECLAMPSIA.     TREAT  JJLKjST. 


to  the  renal  lesions.  Butte  (Revue  H#d. 
de  I'Est,  Mav,  '93). 

Seiies  of  5000  labors  in  which  there 
were  50  cases  of  eclampsia, — i2  in  pri- 
mipane.  Twelve  mothers  died:  10  from 
eclampsia,  1  from  nephritis,  and  1  from 
sepsis.  Geuer  (Centralb.  f.  Gynak.,  No. 
42, '94). 

Maternal  mortality  in  eclampsia,  30 
per  cent.;  foetal  mortality,  46.6  per  cent. 
Tarnier  (Annual,  '9C). 

Series  of  42,007  confinement  cases  137 
— 0.321  per  cent. — of  which  sufTered  from 
eclampsia,  19  being  already  unconscious 
and  many  others  having  had  many  fits 
before  being  admitted  to  the  clinic.  Of 
the  mothers,  109 — 79.5  per  cent. — were 
primiparse;  113  (97  I-parje)  were  not 
more  than  30  years  old.  One  only  had 
had  eclampsia  in  a  previous  (first)  con- 
finement (IV-para;  Csesarean  section). 
Twins  are  noted  12  times;  hydro- 
cephalus, hydramnion,  and  low  lateral 
placenta,  1  each;  abnormal  rotation, 
twice;  abnormal  pelves,  9  times;  3 
breech  cases.  The  attacks  commenced 
before  labor  in  16.78  per  cent.,  during 
it  in  02.04  per  cent.,  and  after  delivery 
in  21.10  per  cent,  of  the  cases;  and 
while  53.17  per  cent,  had  less  than  5 
fits,  the  average  number  of  fits  in  126 
was  8.  Omitting  the  34  children  of  29 
post-partiim  cases,  of  the  remaining  115, 
37 — 32.1  per  cent. — were  still-boni,  and 
56 — 48.6  per  cent. — were  premature.  In 
50.7  per  cent,  of  the  whole,  or  G4.7  per 
cent,  of  the  cases  before  delivery,  empty- 
ing the  uterus  had  a  good  effect.  Of  27 
deaths  (19.7  per  cent.),  17  only  were  due 
to  eclampsia  alone  (12.4  per  cent).  The 
mortality  of  multipara  (6  =  21.4  per 
cent.)  was  greater  than  that  of  primip- 
arse  (21  =  19.2  per  cent.).  The  relative 
mortality  of  cases  commencing  before, 
during,  or  after  childbirth  was  30.43  per 
cent.,  18.82  per  cent.,  and  13.79  per  cent. 
The  proportion  of  deaths  is  compara- 
tively low,  and  with  the  fact  shown  that 
delivery  without  too  active  interference 
tends  to  stop  the  fits  is  sufficient  to 
warrant  the  adoption  of  conservative 
treatment  for  eclampsia.  The  practice 
of  the  A'ienna  clinic  for  many  years  has 
been  a  [irojihylactic  milk  diet  for  all 
albuminuric    pregnant    women;    if    this 


fail,  the  induction  of  labor  by  bougie  or 
colpeurynter.  On  the  outbreak  of  eclamp- 
sia hot  baths,  linden-tea,  wet  packing, 
chloroform,  and  delivery  as  soon  as  may 
be  without  incisions.  Schreiber  (Arch, 
f.  Gyn.,  li,  335,  '96). 

Treatment.  —  The  treatment  of 
eclampsia  may  be  considered  to  advan- 
tage under  the  following  headings:  (1) 
prophylactic;  (3)  medicinal;  (3)  sur- 
gical. 

Prophylactic  Treatment. — If  the  preg- 
nant woman  has  been  carefully  watched 
by  the  medical  attendant,  only  excep- 
tionally will  eclampsia  develop,  because 
the  institution  of  certain  prophylactic 
measures  or  early  resort  to  certain  sur- 
gical measures  will  nullify  or  prevent  the 
development  of  certain  phenomena 
which  apparently  underlie  or  enter  into 
the  causation.  Thus,  it  is  not  sufficient, 
after  a  perfunctory  fashion,  to  examine 
the  urine  for  albumin,  but  the  total 
amount  passed  and  the  amount  of  urea 
contained  in  it  should  be  ascertained  at 
intervals.  Further  still,  explicit  direc- 
tions should  be  given  in  regard  to  the 
necessity  of  securing  free  action  of  the 
sudoriparous  glands  by  means  of  fre- 
quent baths,  and  thorough  action  of  the 
intestinal  canal  should  be  maintained. 
When  the  excretory  organs  of  the  body 
are  acting  physiologically  those  elements 
of  tissue-waste  Avhich,  retained  in  the 
body,  favor  the  development  of  eclamp- 
sia, are  excreted.  AVhcn  skin,  bowels, 
and  kidneys  are  clogged,  the  reverse 
holds  true,  and  sooner  or  later,  in  preg- 
nancy, symptoms  appear  which,  if  not 
properly  appreciated  and  when  possible 
eradicated,  are  forerunners  of  eclampsia. 
When  urinalysis  reveals  the  presence  of 
kidney  disease — whether  organic  or  func- 
tional— steps  should  be  taken  at  once  to 
modify  the  symptomatology  for  the  bet- 
ter by  recourse  to  hygiene  and  dietetics, 
and,  such  measures  failing,  after  reason- 


ECLAMPSIA.    TREATilENT. 


629 


able  interval  medicinal  and  surgical  treat- 
ment enter  the  foreground. 

The  presence  of  albuminuria  is  un- 
doubtedly of  great  value,  but  too  many 
physicians  trust  to  it  alone,  and  the  ex- 
aminations are  made  only  at  long  inter- 
vals. The  medical  man  may  usually  feel 
secure  so  long  as  the  ureal  elimination  is 
near  the  normal, — 400  or  500  grains  per 
diem;  but  this  is  not,  alone,  an  abso- 
lutely reliable  guide.  A  most  important 
and  neglected  element  in  the  prognosis 
is  the  daily  quantity  of  urine.  If  every 
pregnant  woman  were  taught  to  measure 
the  urine  once  or  twice  weekly  during 
the  later  months  of  pregnancy,  and  im- 
pressed with  the  necessity  of  keeping  it 
at  or  above  three  pints  per  day,  convul- 
sions in  childbed  would  be  almost  un- 
known. C.  Jewett  (Brooklyn  Med. 
Jour.,  Aug.,  '99). 

Chief  among  the  hygienic  measures 
stand  hot  baths  and  gentle  catharsis; 
foremost  among  the  dietetic  measures 
ranks  milk  diet  (associated  with  the  ad- 
ministration of  an  assimilable  and  non- 
astringent  form  of  iron). 

Milk  treatment  is  most  efficient  from 
a  prophylactic  point  of  view,  though  it 
does  not  necessarily  cause  the  other 
alarming  symptoms,  besides  the  fits,  to 
vanish.  The  alleged  disappearance  of 
albuminuria  docs  not  necessarily  occur, 
even  after  prolonged  treatment  by  milk 
diet.  The  same  may  be  said  of  the 
oedema ;  this  treatment  seems  to  have  no 
effect  on  it.  The  above  facts  are  em- 
phasized, because  some  obstetricians  have 
very  naturally  given  up  milk  diet  on 
account  of  persistence  of  albuminuria 
and  oedema.  Such  a  step  is  a  mistake, 
for,  if  the  treatment  be  continued,  labor 
will  proceed  without  any  fits  coming  on, 
though  the  legs  remain  swelled  and  the 
urine  albuminous.  FcrrC  (Jj'ObstOtrique, 
Nov.  l.i,  "OG). 

Analysis  of  48  cases.  The  uterine 
douche  alone  was  sufficient  to  check  the 
infective  process  in  15  cases.  Explora- 
tion and  curettage  of  the  uterus  were  fol- 
lowed by  a  rapid  fall  of  temperature  in 


8  cases,  a  gradual  fall  in  10  cases,  a  tem- 
porary increase  followed  by  a  rapid  fall 
in  2  cases,  and  no  effect  on  the  tempera- 
ture in  13  cases.  A.  W.  W.  Lea  (Med. 
Chronicle,  Aug.,  '99). 

There  are  three  main  channels  through 
which  toxic  substances  may  be  got  rid 
of,  viz.:  the  bowels,  the  skin,  and  the 
kidneys.  In  eclampsia  the  urinary  sys- 
tem is  chiefly  at  fault,  but  the  two  other 
channels  must  not  be  neglected.  Hot 
pack  or  bath  to  produce  free  action  of 
the  skin,  with  enemata  to  promote  elim- 
ination of  toxins  by  the  bowels,  and,  to 
get  the  kindeys  to  act,  large  saline  in- 
jections are  advocated.  The  solution 
used  was  1  part  of  bicarbonate  of  potash 
to  1  of  common  salt:  1  drachm  to  the 
pint  of  sterilized  water  at  100°  F.  The 
bicarbonate  of  potash  is  added  to  obtain 
the  diuretic  action  of  the  potash  salts. 
The  apparatus  used  is  an  aspirator 
trocar  and  cannula,  a  few  feet  of  rubber 
tubing,  a  test-tube-shaped  filler,  and  a 
piece  of  adhesive  plaster.  The  injection 
is  made  conveniently  under  the  edge  of 
the  breast  before  deliverj';  the  lax  ab- 
dominal wall,  after  delivery.  From  1  to 
4  pints  may  be  employed.  Absorption 
begins  at  once,  and  is  complete  in  fifteen 
or  twenty  minutes.  In  seventeen  cases 
saline  injections  were  employed  to  in- 
crease the  flow  of  urine,  and  so  aid  elimi- 
nation by  the  kidneys.  Analysis  showed 
a  marked  increase  in  the  daily  excretion 
of  urea  and  uric  acid,  and  there  is  prob- 
ably a  corresponding  increase  in  the  ex- 
cretion of  the  poison  which  causes  the 
disease.  Jardine  (Practitioner,  Dec., 
'99). 

It  has  been  definitely  shown  that  the 
vagina  is  sterile  in  healthy  women. 
Therefore,  it  they  get  infected  at  labor 
it  is  through  some  intravaginal  manipu- 
lation. Prophylaxis  reduces  itself  to 
two  measures:  (1)  Clean  hands  and  in- 
struments. (2)  Avoidance  of  vaginal 
examinations.  With  regard  to  the  ster- 
ilization of  tlie  hands,  Stewart's  method 
is  the  best.  Vaginal  examinations  can 
usually  be  dispensed  with.  It  is  to  be 
regretted  that  this  practice  is  not  more 
usual.  Brodhend  (Medical  Record,  April 
23,  1904). 


630 


ECLAMPSIA.     TREATMENT. 


Where,  notwithstanding  these  meas- 
ures, the  evidences  of  organic  kidney  dis- 
ease become  intensified,  or  where,  these 
evidences  lacking,  the  symptoms  sug- 
gestive of  impending  eclampsia  develop, 
time  for  action  has  come,  justifiable  de- 
lay having  reached  its  limit.  In  the  past 
and  even  to-day  expectancy  has  been  and 
is  too  often  the  cause  of  untoward  re- 
sults. 

"With  the  exception  of  the  fulminating 
type  of  eclampsia — where  art  almost  al- 
ways fails,  it  may  be  stated  that  prompt 
action,  of  the  nature  to  be  described,  will, 
in  the  vast  proportion  of  cases,  prevent 
the  development  of  eclampsia. 

Medicinal  Treatment. — In  the  pres- 
ence of  the  prodromal  symptoms  of 
eclampsia,  but  little  reliance  can  be 
placed  on  drugs.  Where  urinary  insuffi- 
ciency exists,  indeed,  it  is  very  question- 
able if  the  routine  administration  of 
drugs  do  not  harm.  Certainly  the  potas- 
sium salts  are  very  likely  to  irritate  the 
kidneys.  The  ingestion  of  large  amounts 
of  water  by  mouth  and  repeated  intro- 
duction of  warm  normal  .saline  solution 
into  the  blood-stream  will  accomplish 
more  than  any  and  all  drugs  together. 

Van  Eenssalaer  suggests  venesection, 
canied  to  the  point  of  tolerance,  and 
then  followed  by  the  subcutaneous  injec- 
tion of  a  normal  salt  solution.  This 
method  need  not  be  confined  to  the 
plethoric,  but  even  a  weak  pulse  and 
profound  coma  do  not  contraindicate  its 
use,  for  the  rapid  introduction  of  the 
warm  salt  solution  following  venesection 
counteracts  the  effects  of  bleeding,  filling 
the  vessels  and  stimulating  the  heart. 
From  a  pint  to  a  quart  of  blood  can  be 
safely  withdrawn  from  the  veins  of  a 
patient  of  average  weight,  providing  the 
injection  of  the  salt  solution  is  followed 
up  at  once.  J.  L.  Rolhrock  {North- 
western Lancet,  Nov.  15,  '97). 

Series  of  cases  of  puerperal  eclampsia 
treated  by  rest,  pure  milk  diet,  injec- 
tions of  morphine  to  control  convulsions. 


and  the  regular  administration  of  thy- 
roid extract  in  doses  of  0.30  gramme 
(5  grains),  repeated,  if  necessary,  every 
three  or  four  hours.  The  symptoms, 
especially  headache,  albumin  in  the 
urine,  oedema,  amblyopia,  etc.,  began  and 
steadily  continued  to  disappear.  Thy- 
roid extract  is  also  of  value  to  prevent 
convulsions  in  women  who  give  a  his- 
tory of  eclamptic  seizures  during  pre- 
vious pregnancies.  H.  0.  Nicholson  (La 
Semaine  Mfidicale,  May  21,  1902). 

As  regards  treatment  in  the  early 
stages,  when  there  are  Increased  tension 
of  pulse  and  diminution  of  urine  thyroid 
extract  should  be  given  twice  or  thrice 
daily,  and  proteid  foods  should  be  en- 
tirely forbidden  at  first.  Iodide  of  po- 
tassium in  small  doses  has  been  re- 
garded as  a  specific  for  puerperal  albu- 
minuria; the  iodine  has  been  proved 
to  be  picked  out  by  the  thyroid  gland 
and  may  be  elaborated  into  the  active 
iodothj'riu.  It  has  been  suggested  to 
give  infusions  with  iodide  of  potassium 
instead  of  ordinary  saline  infusions  in 
cases  of  eclampsia.  If  convulsions  have 
already  occurred,  then  the  use  of  thy- 
roidin  by  the  mouth  will  not  be  rapid 
enough.  Liquor  thyroidii,  or,  better 
still,  fresh  thyroid  juice,  from  10  to  15 
minims,  should  be  given  by  hypodermic 
injection  and  repeated  every  hour  or 
two  if  not  followed  by  signs  of  improve- 
ment. For  the  immediate  treatment  of 
the  convulsion  morphine  is  the  best 
remedy.  It  inhibits  the  various  proc- 
esses of  metabolism,  and  this  gives  op- 
portunity to  the  thyroid  gland  to  re- 
cover itself.  The  dose  should  be  large: 
not  less  than  Va  grain  for  the  first 
injection.  H.  0.  Nicholson  (Lancet, 
June  29,  1901). 

Intravascular  antisepsis  appeals  to 
the  mind  of  every  scientific  observer  of 
septic  conditions  of  the  blood.  An  in- 
travascular antiseptic  or  germicide  must 
be  destructive  to  bacteria  and  at  the 
same  time  not  injure  the  patient.  For- 
maldehyde possesses  this  specific  influ- 
ence, as  shown  by  experiments  on  ani- 
mals. Maguire  used  solutions  upon 
himself  as  strong  as  1  to  500  without 
any  liromolytie  changes.     Case  of  septi- 


ECLAIIPSIA.    TREATMENT. 


631 


ceeraia  personally  treated  with  success 
by  formalin  injections,  using  an  aqueous 
solution,  1  to  5000.  FormaUn  in  nor- 
mal salt  solution  would  be  better  than 
aqueous  solution,  althougli  no  haemoly- 
sis follows  the  infusion  of  formalin  in 
distilled  water.  Theoretically,  however, 
salt  solution  is  preferable.  Barrows 
(New  York  Medical  Journal,  Jan.  31, 
1903). 

The  saline  irrigation — if  a  number  of 
quarts  are  used  at  a  time — promotes  di- 
uresis and  diaphoresis  and  indirectly  en- 
forces intestinal  peristalsis,  and  such  irri- 
gation should  become  the  established 
custom  not  alone  in  face  of  impending 
eclampsia,  but  also  in  the  presence  of 
eclampsia.  "\ATiere  the  pulse  of  tension 
exists  venesection — too  seldom  resorted 
to  nowadays — is  called  for. 

Saline  transfusion  should  be  resorted 
to  if  the  patient  is  in  a  collapse  and 
death  seems  imminent.  Tliese  hypoder- 
mic injections  of  warm  sterilized  water, 
salt  (1  per  cent.),  to  the  amount  of  one- 
half  pint,  into  the  vascular  tissues  of 
the  axillre  W'ill  be  readily  absorbed.  G. 
Covert  (Chicago  Medical  Times,  Apr., 
'98). 

Inasmuch  as  eclampsia  is  undoubtedly 
a  to.xnomia,  one  should  look  for  good  re- 
sults from  the  intracellular  transfusion 
of  saline  solution.  Bacon's  apparatus 
consists  of  a  glass  funnel  and  long  rub- 
ber tube,  which  is  connected  by  means 
of  a  Y-shaped  glass  tube  and  two  short 
rubber  tubes  with  two  aspirator  needles. 
The  solution  can  be  injected  into  the  two 
axillte  at  the  same  time,  and  thus  the 
main  objection  against  the  intracellular 
contrasted  with  the  intravenous  method 
may  be  in  great  part  obviated.  Edgar 
(Glasgow  Med.  Jour.,  Apr.,  '99). 

Three  cases  of  eclampsia  treated  by 
saline  infusion.  As  soon  as  the  patient 
rouses  sufTiciently,  drachm  doses  of  Ep- 
som salts  every  hour  are  given.  The 
salt  solution  usually  acts  wonderfully 
in  stimulating  the  kidneys;  but,  if  neces- 
sary, diy  and  wet  cups  may  be  used 
with  Va  ounce  of  infusion  of  digitalis 
every  four  hours.    The  diet  is  exclusively 


milk.  To  stimulate  the  skin,  the  hot- 
air  bath  or  the  wet  pack  is  used.  Tonics 
are  given  during  convalescence.  Allen 
(Amer.  Jour,  of  Obstet.,  May,  '99). 

The  experiments  of  Tarnier,  Ludwig, 
and  Savor  certainly  show  that  the  tox- 
icity of  the  blood-serum  is  increased  in 
eclampsia,  while,  on  the  other  hand, 
those  of  Charrin  and  Volhard  seem  to 
prove  just  as  conclusively  that  it  is  not. 
In  treatment,  prophylaxis  stands  pre- 
eminent. When  the  trouble  has  devel- 
oped the  treatment  may  be  summed  up 
in  one  word,  "elimination,"  and  nothing 
will  give  such  immediate  results  as 
bloodletting,  followed  by  infusion  or 
transfusion  of  saline  solution.  If  the 
patient  be  ansemic,  do  not  bleed,  but 
use  the  saline  injection.  The  results  of 
such  treatment  observed  to  the  eflfect 
that:  (1)  the  patient's  general  condi- 
tion will  improve;  (2)  the  cyanosis, 
muscular  twitching,  and  rigidity  will 
have  ceased;  (3)  the  pulse,  which  before 
was  hard  and  bounding,  will  have  lost 
its  tenseness,  and  the  attendant  coma, 
be  it  never  so  deep,  will  slowly,  but 
surely,  be  lifted.  The  writer  says,  in 
conclusion,  that  if  bloodletting,  together 
with  saline  infusion  or  transfusion,  were 
more  generally  emplojed,  better  results 
would  be  obtained  in  the  treatment. 
E.  T.  Abrams  (Amer.  Jour,  of  Obstet- 
rics, Jan.,  1903). 

Possibly  veratrum  viride  administered 
hypodermically  every  two  or  three  hours 
in  the  dosage  of  10  minims,  until  the 
pulse-rate  is  materially  lowered  (down  to 
60  or  40)  will  accomplish  the  same  result 
as  venesection,  and  at  times  the  free  use 
of  this  drug  will  render  unnecessary  re- 
sort to  active  surgery,  except  where  the 
symptoms  are  very  urgent,  when  we  are 
amply  satisfied  that  dallying  with  drugs 
should  cease. 

Twenty-six  cases  with  no  deaths 
treated  with  veratrum  viride  by  the 
mouth  or  subcutancously  until  pulse 
had  been  lowered  below  CO  and  con- 
vulsions controlled,  after  which  the  fol- 
lowing mixture  given: — 


632 


ECLAMPSIA.    TKEATJIEiS'T. 


IJ  Acidi  benzoic!,  2  drachms. 
Potass,  bicarb.,  V:  ounce. 
Spirit,  aether,  nit.,  1  ounce. 
Spirit.  Mindereri,  2  ounces. 
SjT.  limonis,  q.  s.  ad  6  ounces. 
M.     Sig.:     A   teaspoonful   every   four 
hours.    R.  C.  Newton  (N.  Y.  Med.  Jour., 
Dec.  14,  '95). 

The  toxins  causing  uremia  are  varied 
and  numerous.  In  eclamptics  the  urine  is 
less  toxic  than  normal,  while  the  blood- 
serum  is  more  toxic.  The  foetus  is  an 
additional  source  of  waste-products  and 
an  additional  cause  of  danger  to  the 
mother.  The  indications  for  treatment 
are  to  remove  the  to.xic  materials  in 
every  way  practicable.  Veratrum  viride 
in  cases  where  the  pulse  is  strong  enough 
to  warrant  its  employment  will  be  found 
useful.  The  depressing  action  of  pilocar- 
pine makes  it  a  dangerous  drug.  Many 
patients  with  eclampsia  die  from  over- 
medication.  Labor  should  be  induced  or 
delivery  hastened  when  other  methods 
fail  to  control  the  convulsions.  P.  W. 
Van  Peyma  (N.  Y.  Med.  Jour.,  Feb.  22, 
'96). 

The  method  by  which  veratrum  viride 
is  supposed  to  do  good  in  cases  of  puer- 
peral eclampsia  is  a  double  one.  Chiefly 
from  the  action  of  its  alkaloid,  jervine, 
it  powerfully  depresses  the  circulation, 
and  so  bleeds  the  woman  into  her  own 
vessels,  relieving  by  this  means  conges- 
tion of  the  cerebral  and  spinal  vessels 
and  reducing  in  all  probability  any 
spasm  of  the  renal  blood-vessels  which 
may  be  present,  thereby  causing  marked 
increase  in  the  flow  of  urine.  In  addi- 
tion to  this  action,  jervine  also  acts  as  a 
powerful  .sedative  to  the  motor  tracts  of 
the  spinal  cord,  and  so  directly  quiets 
nervous  excitation,  while  the  copious 
sweating  which  often  follows  its  admin- 
istration aids  in  relieving  the  blood  of 
impurities,  the  kidneys  of  congestion, 
and  relaxes  the  peripheral  blood-vessels. 
Editorial  (Therap.  Gaz.,  Mar.  10,  '00). 

Veratrum  viride  used  with  marked 
BuccesB.  The  remedy  notably  diminishes 
the  frequency  of  the  pulse,  and  convul- 
BJonH  rarely  occur  when  the  pulse  is 
kept  at  or  below  00.  Of  100  patients 
treated     by     veratrum     viride     in     the 


writer's  practice,  92  were  saved.  Parvin 
(Universal  Med.  Jour.,  Oct.,  '913). 

During  the  attack  itself  chloroform 
administered.  As  soon  as  the  attack 
passes,  15  drops  of  the  fluid  extract  of 
veratrum  viride  are  given  hypodemiic- 
ally,  and  a  drachm  of  chloral  in  solution 
by  enema.  Two  drops  of  croton-oil  di- 
luted with  a  little  sweet  oil  are  placed 
upon  the  tongue.  Diaphoresis  is  induced 
by  hot  packs  and  extra  bed-clothing. 
A  pint  or  more  of  decinormal  salt  solu- 
tion should  he  injected  by  gravity  under 
the  breast,  or  several  quarts  of  the  solu- 
tion by  enema.  If  convulsions  recur,  the 
veratrum  may  be  repeated  in  5-drop 
doses  if  the  pulse  is  quick  and  strong. 
If  the  face  is  congested  and  the  pulse 
full,  venesection  enough  to  reduce  the 
pulse  should  be  employed.  The  chloral 
may  be  repeated  during  the  attack  two 
or  three  times.  Stimulants  are  to  be  used 
if  the  pulse  is  weak  and  rapid.  If  the 
convulsions  cease  and  the  patient  is  in  a 
stupor,  but  can  be  aroused  enough  to 
swallow,  dessertspoonfuls  of  concentrated 
solution  of  Epsom  salts  should  be  given 
every  fifteen  or  thirty  minutes  until  free 
catharsis  takes  place.  B.  C.  Hirst  (Med. 
Record,  Mar.  4,  '99). 

In  five  personal  cases  of  eclampsia 
there  was  not  a  single  convulsion  after 
ether  had  been  thoroughly  given,  though 
in  these  eases  many  convulsions  had  fol- 
lowed other  lines  of  treatment.  The 
harmlessness  of  continuous  and  thorough 
anaesthesia  is  emphasized.  In  the  five 
cases  anfesthesia  was  kept  up  from  eight 
to  twenty-four  hours,  deeply  enough  to 
keep  the  patient  quiet,  and  there  was 
not  a  single  symptom  that  showed  that 
any  of  the  women  was  any  the  worse 
for  the  anoesthetie.  J.  P.  Reynolds 
(Boston  Med.  and  Surg.  Jour.,  Nov.  9, 
'99). 

Veratrum  viride  is  the  remedy  par  ex- 
cellence in  eclampsia,  acting  to  reduce 
arterial  tension  and  to  soften  the  rigid 
OS,  thereby  removing  the  causes  pro- 
ducing the  malady.  F.  L.  Brighara 
(Amcr.  Gynrec.  and  Obstct.  Jour.,  Dec, 
'99). 

Nitroglycerin,  in  the  dosage  of  Vu 
grain,  hypodermically,  repeated  pro  re 


ECLAilPSIA.     TREATMENT. 


633 


nata  will  tend  to  relieve  the  cephalalgia. 
When  the  convulsions  appear  suddenly 
morphine,  1  grain  hypodermically,  is 
called  for  until  chloroform  anesthesia 
to  the  surgical  degree  is  secured;  but 
otherwise  opium  and  its  derivatives 
should  not  be  countenanced,  because  of 
their  tendency  to  inhibit  secretion  from 
the  intestinal  canal  and  from  the  kid- 
neys, thus  defeating  the  prime  thera- 
peutic aim,  which  is  to  increase  secretion 
and  excretion. 

Case  of  puerperal  infection  treated  by 
Marmorok's  antistreptococcic  serum  with 
very  successful  results.  Other  drugs 
were  used  with  no  beneficial  effects;  but, 
upon  beginning  the  serum-treatment,  im- 
provement was  steady  and  rapid,  and 
four  days  after  the  first  injection  the 
temperature  was  normal.  R.  de  Seig- 
neaux  (Centralb.  f.  Gynilk.,  Dec.  16,  '99). 
The  pathological  features  and  symp- 
toms that  require  treatment  are:  The 
toxajmia,  ana;mia,  the  convulsions,  the 
labor-pains,  hypersensitiveness  of  the 
nervous  system,  to  avoid  causing  oedema 
of  the  lungs,  heart-failure,  and  high- 
tension  pulse. 

For  tlie  toxtemia,  elimination  by  pur- 
gation with  calomel,  accompanied  by 
magnesium  sulphate  in  Vj-ounce  doses 
of  the  saturated  solution.  In  antepar- 
tum cases  this  purgation,  with  an  occa- 
sional dose  of  calomel,  must  be  kept  up 
until  the  child  is  born.  One  of  personal 
cases  carried  on  in  this  way  after  the 
patient  had  had  eight  convulsions  for 
seven  weeks,  when  a  healthy  child  was 
born,  and  thrived.  In  2  cases  it  hap- 
pened that  when  the  morning  course  of 
salines  was  omitted,  owing  to  the 
bowels  having  moved  early  in  the  morn- 
ing, convulsions  came  on  again  at  night. 
In  1  of  them,  after  the  patient  had  been 
kept  free  from  convulsions  for  a  week. 
In  case  of  unconsciousness,  2  minims  of 
crotonoil  may  be  introduced  through  a 
stomach-tube. 

Normal  saline  solution  given  subcu- 

taneously  acts  very  well  as  a  diuretic. 

K.  C.  Mcllwraith  (Canadian  Pract.  and 

Rev.,  June,  1901). 

The  serum-treatment  has  no  place  in 


the  routine  treatment  of  puerperal  sep- 
sis; it  should  be  used  only  in  desperate 
cases  after  failure  to  obtain  improve- 
ment by  other  and  usually  more  efiB- 
cient  methods,  and  if  no  improvement 
is  shown  after  use  for  two  or  at  moat 
three  days  and  the  injection  of  40  to 
00  cubic  centimetres  (10  to  1.5  flui- 
drachms),  it  should  be  discontinued.  Its 
use  is  not  free  from  danger,  it  usually 
lowers  the  pulse  and  temperature,  but 
at  the  same  time  it  has  a  correspond- 
ingly depressing  effect  upon  the  patient, 
and  it  has  not  apparently  lowered  the 
mortality  of  the  disease. 

With  regard  to  the  general  treatment 
of  puerperal  sepsis,  early  curettage  of 
the  uterus  carefully  performed  as  soon 
as  the  diagnosis  is  established  is  of  pri- 
mary importance,  and  the  same  result 
is  not  accomplished  by  any  other 
method  of  procedure.  Following  curet- 
tage, and  sometimes  in  place  of  it  in 
the  mild  cases,  intra-uterine  douches 
have  proved  to  be  of  much  value.  For 
constitutional  treatment,  one  must 
mainly  rely  on  stimulation,  tonics,  and 
forced  feeding,  with  moderate  diuresis 
and  catharsis.  F.  A.  Higgins  (Boston 
Med.  and  Surg.  Jour.,  May  2,  1901). 

These  few  drugs  failing  to  control  the 
premonitory  symptoms  or  eclampsia  sud- 
denly developing,  measures  of  a  surgical 
nature  are  called  for. 

Surgical  Treatment.  —  Where  the 
symptoms  which  forebode  the  develop- 
ment of  eclampsia  do  not  yield  to  the 
dietetic,  hygienic,  and  medicinal  treat- 
ment outlined,  the  surgical  measure  de- 
manded is  evacuation  of  the  uterus. 

In  eclampsia  occurring  during  partu- 
rition delivery  should  be  effected  as 
quickly  as  possible  under  deep  anresthe- 
sia.  When  possible,  without  loss  of 
time,  the  cervix  should  be  widened  by 
hydrostatic  dilators,  and  the  smallest 
possible  incision,  ^^^len  the  condition  of 
the  cervix  is  the  cause  of  delay  after 
artificial  dilatation,  incision  as  deep  as 
may  be  necessary  should  be  made. 
Hicmorrhage  arising  from  this  cause 
may  be  controlled  by  tampons  of  gauza 
or  by  pressure-forceps.     In  such  cases, 


634 


ECLAMPSIA.    TREATilEXT. 


considering  the  amount  of  hsemorihage 
from  the  incision,  there  can  never  be  any 
question  of  adopting  venesection.  Wlien 
the  patient  is  unconscious,  no  attempt 
should  be  made  to  make  her  swallow;  a 
suitable  stomach-pump  should  be  iu- 
variablj-  used  for  the  introduction  of 
nourishment  or  medicine.  Anaesthetics 
should  be  used  to  the  surgical  extent 
only  during  the  operation  of  emptying 
the  uterus,  and  either  chloroform  or 
ether  may  be  used.  The  most  exact 
asepsis  is  required;  infection  prolongs 
the  convulsion  stage  of  eclampsia.  P. 
Zweifel  {Centralb.  f.  Gyntik.,  Nos.  4G  to 
48,  '95). 

In  the  Prague  hospital  the  rule  is  to 
deliver  as  rapidly  as  possible  consistent 
with  avoiding  injury.  A  mi.xture  of 
chloroform,  ether,  and  alcohol  is  an  espe- 
cially safe  preparation,  the  anaesthetic 
being  administered  not  only  during  the 
operative  proceedings,  but  also  to  mod- 
ify the  convulsions.  Morphine  is  also 
constantly  employed.  The  prolonged 
warm  bath  and  the  hot  wet  pack  are 
very  important.  The  only  beverage  per- 
mitted is  lukewarm  milk.  Knapp 
(Monats.  f.  Geburts.  u.  Gyniik.,  B.  3, 
May  and  June,  '90). 

Albuminuria  is  a  premonitory  sign  too 
important  to  be  overlooked.  Termina- 
tion of  the  delivery  is  in  all  cases  de- 
sirable, and  it  must  be  rapidly  brought 
about  in  serious  cases.  Therefore  from 
the  beginning  of  the  attacks  we  must 
act  continuously  in  that  direction.  In 
very  urgent  circumstances  we  must  not 
hesitate  to  dilate  the  cen'ix.  If  this 
accouchement  ford  is  difficult,  too  slow, 
or  impossible  without  too  much  injury, 
we  must  have  recourse  to  Cesarean  sec- 
tion. N.  Charles  (Jour.  d'Accouohe- 
ments,  Oct.  11,  '90). 

In  puerperal  eclampsia  the  chief  aim 
is  to  empty  the  uterus  of  its  contents  as 
quickly  as  possible.  The  cervical  canal 
should  be  dilated,  first  by  means  of 
Hegar's  graduated  sounds  and  afterward 
with  the  fingers,  until  the  orifice  has 
attained  a  diameter  of  three  centimetres. 
Podalic  version,  according  to  the  Jirax- 
ton-Hick8  method,  is  then  practiced  and 
one  loot  extracted.  This  done,  the  uter- 
ine orifice  is  again  dilated  by  separating 


its  edges  on  one  side  by  means  of  the 
child's  leg,  upon  which  the  hand  of  the 
operator  exerts  (the  foot  being  already 
extracted  from  the  wound)  energetic 
lateral  pressure,  and  on  the  opposite 
side  with  the  hooked  inde.x  of  the  other 
hand.  When  dilatation  of  from  eight  to 
ten  centimetres  has  thus  been  obtained, 
it  only  remains  to  extract  the  child.  As 
soon  as  the  umbilical  cord  has  been 
severed  the  placenta  should  be  detached 
and  the  uterus  compressed  with  the  two 
hands  for  about  an  hour;  this  com- 
pression suscitates  the  uterine  contrac- 
tions, preventing  any  serious  hfemor- 
rhage.    Drejer  (Sem.  M6d.,  Oct.  31,  '96). 

Acceleration  of  labor  by  safe  methods, 
large  doses  of  morphine  to  suppress  the 
attacks,  avoidance  of  administering  med- 
icine by  the  mouth,  stimulation  of  dia- 
phoresis by  external  remedies — all  these 
appear  to  promise  most  success  in  treat- 
ment.  Veit  (Festschrift  f.  Carl  Ruge,'96) . 

Whenever  albumin  is  discovered  in  the 
urine  of  a  pregnant  woman,  she  should, 
without  delay,  be  put  upon  a  strict  milk 
diet,  for  albuminuria  is  to  be  regarded 
as  a  symptom  of  the  state  of  autoin- 
toxication which  results  in  eclampsia. 
Tarnier  says  that  he  has  never  seen 
eclampsia  supervene  in  pregnant  women 
suffering  from  albuminuria  who  have 
been  for  seven  days  upon  a  strict  milk 
diet.  During  the  convulsions  tlie  tongue 
is  best  preserved  from  injury  by  placing 
a  folded  handkerchief  between  the  teeth, 
which  pushes  the  tongue  back,  and  also 
prevents  the  teeth  from  closing.  The  pa- 
tient should  be  placed  immediately  under 
the  induence  of  chloroform.  A  rectal 
injection  of  about  GO  grains  of  chloral 
should  next  be  given;  it  is  advisable 
to  begin  with  a  large  dose  rather  than 
repeated  small  doses.  If  necessary  the 
injection  of  chloral  may  be  repeated  sev- 
eral times,  giving  as  much  as  2.50  to  300 
grains  in  twenty-four  hours.  The  in- 
halation of  chloroform  should  be  con- 
tin\ied  during  the  attacks.  Bleeding  is 
reserved  for  the  rare  cases  which  are  dis- 
tinctly "sthenic"  in  type.  As  a  diuretic 
agent,  half  a  pint  or  more  of  a  saline 
solution  containing  1  per  cent,  of  chlo- 
ride of  sodium,  may  be  injected  into  the 
buttock,  and  the  injection  repeated  scv- 


ECLAMPSIA. 


635 


eral  times.  No  interference  is  required 
until  the  cervi.x  is  fully  dilated,  when 
the  child  may  be  extracted  with  forceps 
or  by  turning.  Delivery  by  such  forcible 
methods  as  rapid  dilatation  or  incision 
of  the  ccrvi.x  is  condemned.  Oui  (L'Echo 
M6d.  du  Nord,  May,  'i)7). 

The  treatment  consists  in  controlling 
the  convulsions  by  profound  narcosis, 
speedy  evacuation  of  the  uterine  con- 
tents, and  diaphoresis,  with  a  view  to  re- 
establish skin  function  and  reduce  tlie 
tension.  Kedarnath  Dass  (Indian  Med. 
Record,  April  IG,  '98). 

The  nearer  the  term,  the  easier  the  pro- 
cedure of  emptying  the  uterus;  the  same 
statement  applies  to  the  multipara  over 
the  primipara.  The  steps  of  the  pro- 
cedure are,  in  brief,  the  following:  Un- 
der the  most  absolute  asepsis  of  patient, 
instruments,  and  hands  of  operator  and 
assistants,  ordinarily  under  chloroform 
antesthesia,  the  cervix  is  dilated  by  the 
steel-branched  or  other  dilator.  Great 
care  is  requisite  not  to  rupture  the  mem- 
branes. The  cervical  canal  is  then  firmly 
packed  with  sterile  gauze,  and  the  upper 
portion  of  the  vagina  as  well.  The 
woman  is  put  to  bed  and  if  she  complain 
of  much  pain  codeine  should  be  used 
freely  in  suppository  (gr.  ii  to  iv  repeated 
every  four  to  six  hours),  for  reflex  nerv- 
ous irritability  must  be  controlled.  At 
the  expiration  of  about  twenty-four 
hours,  under  absolute  asepsis  and  chloro- 
form ansEsthcsia,  the  gauze  is  removed, 
and,  if  the  cervix  has  softened  and  is 
dilatable,  manual  dilatation  is  resorted 
to.  If  the  cervix  has  not  softened  and 
the  symptoms  are  not  urgent  the  canal 
should  be  repacked  for  a  further  period 
of  about  twenty-four  hours.  Dilatation 
by  the  hand  having  been  accomplished  to 
the  requisite  degree — that  is  to  say,  until 
the  closed  fist  can  be  withdrawn  with 
ease,  the  membranes  being  intact,  elect- 
ive version  is  performed,  followed  by  im- 
mediate extraction,  else  the  lower  uterine 


segment  may  close  on  the  fcetal  head. 
When  the  membranes  have  ruptured  de- 
livery from  the  brim  by  axis-traction  for- 
ceps is  indicated.  After  delivery — when 
the  pulse  is  full,  strong,  bounding — uter- 
ine venesection  is  allowable  until  the 
pulse  becomes  soft.  'Where,  on  the  other 
hand,  the  pulse  after  delivery  is  rapid 
and  weak,  no  time  should  be  lost  in  the 
thorough  uterine  tamponade. 

'Where  eclampsia  develops  without  pre- 
monitory symptoms,  or  where  delay  with 
the  premonitory  symptoms  has  ruled, 
there  is  no  time  for  the  preliminary  tam- 
ponade. Under  absolute  asepsis  and 
chloroform  anaesthesia  manual  dilatation 
is  at  at  once  instituted,  associated,  in 
very  rare  instances,  with  the  Diihrssen 
incisions,  the  uterus  being  then  emptied. 

In  post-partum  eclampsia  there  is  no 
scope  for  surgery,  and  dependence  must 
rest  on  drugs  (veratrum  and  the  nitrites), 
on  repeated  high  saline  rectal  irrigation, 
and  in  free  catharsis,  using  elaterium  or 
croton-oil.  'Whether  the  case  be  of  the 
sthenic  or  asthenic  type,  these  rules  hold 
good,  except  that  in  the  latter  type  hy- 
podermoclysis  of  saline  solution  should 
be  added,  and  in  the  latter  venesection. 
Egbert  H.  Grandin, 

New  York. 

ECZEMA.— Gr.,  fx^to'.  to  boil  over. 

Definition. — Eczema  may  either  be  an 
acute,  subacute,  or  chronic  inflammatory 
disease  of  the  skin,  usually  characterized 
in  its  earliest  stages  by  the  appearances  of 
erythema,  papules,  vesicles,  or  pustules, 
or  a  combination  of  two  or  more  of  these 
lesions.  It  is  attended  with  a  variable 
degree  of  thickening  and  infiltration  of 
the  cutaneous  tissues,  terminating  either 
in  discharge  with  the  formation  of  crusts 
or  in  absorption  or  in  desquamation. 

Varieties. — The  primarj-,  or  element- 
ary, varieties  are  the  er}'thematous,  papu- 
lar, vesicular,  and  pustular;   or  the  first 


636 


ECZEMA.    SYMPTOMS. 


outbreak  may  show  a  mixture  of  these 
several  types.  In  many  cases  the  begin- 
ning lesions  or  type  soon  lose  their  char- 
acters and  the  disease  develops  into  the 
common  clinical  varieties:  eczema  ru- 
brum  or  eczema  squamosum.  Other 
clinical  or  secondary  types  met  with  are 
eczema  fissum,  eczema  sclerosum,  and 
eczema  verrucosum. 

Symptoms. — The  erythematous  tj'pe  of 
eczema — also  called  eczema  erj'thema- 
tosum — is  most  frequently  seen  upon  the 
face,  although  it  may  make  its  appear- 
ance upon  any  other  region  or  may 
be  more  or  less  general.  It  begins  as  a 
single  hypersemic  area,  or  several  areas 
may  appear  simultaneously,  usually 
upon  one  region.  The  areas  may  be 
email  or  large,  irregularly  outlined,  ill 
defined,  and  attended  with  slight  or  con- 
siderable swelling  and  even  oedema. 
There  is  more  or  less  itching  and  burn- 
ing. The  eruption  soon  becomes  pro- 
nounced, the  parts  reddened,  somewhat 
thickened,  and  here  and  there  a  little 
scaly.  There  may  also  be,  here  and  there 
(as  a  result  of  rubbing  or  scratching,  or 
spontaneously)  a  tendency  to  serous  ooz- 
ing. The  affected  skin  is  harsh,  dry,  and 
reddish  or  violaceous  in  color.  It  often 
persists  in  this  form,  and  the  skin  may 
become  considerably  thickened  and  in- 
filtrated. The  swelling  and  oedema 
which  are  often  first  present  may  sub- 
side, to  a  great  extent  at  least,  or  these 
symptoms  may  reappear  from  time  to 
time  whenever  there  is  an  acute  exacer- 
bation. The  parts  may  become  quite 
scaly,  and  constitute  a  mild  or  well- 
marked  scaly  eczema:  eczema  squamo- 
sum. Occasionally,  as  a  result  of  con- 
stant irritation,  rubbing,  and  scratching, 
or  from  other  causes,  the  parts  become 
moist,  markedly  inflamed,  with  more  or 
less  crusting,  consUtuting  eczema  ru- 
brum. 


The  papular  type  of  the  disease,  or  ec- 
zema papulosum,  presents  itself  as  one  or 
more  aggregations  of  closely-set  papules, 
pin-point  to  pin-head,  or  slightly  larger, 
in  size.  The  disease  may  also  show  itself 
as  more  or  less  discrete  papules,  with 
here  and  there  aggregations.  In  color 
the  lesions  are  bright-  or  deep-  red  or 
violaceous,  with  often  a  few  vesicles  or 
pustules  interspersed.  Itching  is  usually 
intense.  The  extremities,  and  the  parts, 
especially  about  the  joints,  are  its  favor- 
ite sites.  The  course  of  this  type  is  es- 
sentially chronic,  some  lesions  disappear- 
ing and  others  appearing,  and  thus  per- 
sisting for  several  months  or  indefinitely. 
In  some  instances,  especially  in  some 
areas,  the  papules  become  so  thickly 
crowded  that  a  solid  patch  results,  be- 
coming more  or  less  scaly — eczema 
squamosum.  Or  at  times  such  a  patch 
may  develop  into  eczema  rubrum. 

The  vesicular  type  of  the  disease,  or 
eczema  vesiculosum,  may  show  itself  on 
one  or  more  regions,  and  consists  of  ag- 
gregated or  closely-crowded  pin-point  to 
pea-sized  vesicles,  with  here  and  there 
discrete  lesions,  and  at  times  with  pap- 
ules and  pustules  interspersed.  It  is 
usually  a  markedly-inflammatory  type, 
with  considerable  cederaa  and  swelling. 
Solid  sheets  of  eruption  may  form.  The 
vesicles  usually  rupture  in  the  course  of 
a  few  hours  or  days,  new  outbreaks  oc- 
curring, or  a  raw  weeping,  more  or  less 
crusted  surface  resulting.  The  oozing 
may  be  continuous  or  the  process  may 
decline,  to  remain  quiescent  or  to  break 
forth  rapidly  with  repeated  vesicular 
crops.  Considerable  thickening  may 
take  place  and  with  the  oozing  and  crust- 
ing make  up  a  picture  of  the  common 
clinical  type:  eczema  rubrum.  The  face 
and  scalp  of  infants,  the  neck,  flexor  sur- 
faces and  fingers  are  the  more  common 
sites  for  the  vesicular  type.    Its  course  is 


ECZEJIA.    SYilPTOMS. 


637 


usually  chronic,  with  several  acute  ex- 
acerbations, or,  as  already  described,  it 
may  pass  sooner  or  later  into  the  com- 
mon clinical  type:  eczema  rub  rum. 

The  pustular  variety  of  eczema,  or  ec- 
zema pustulosum  or  impetiginosum,  is 
less  frequently  met  with  than  the  other 
varieties  of  the  disease.  Its  common 
site  is  the  scalp,  especially  in  infants.  It 
may  develop  from  the  vesicular  variety, 
or,  as  more  commonly  the  case,  begin  as 
closely-set  pin-point  to  pin-head,  or 
larger  sized  pustules;  or  a  mixture  of 
vesicles  and  pustules  may  be  noticed.  In 
symptomatology  it  is  similar  to  eczema 
vesieulosum,  except  that  the  lesions,  in- 
stead of  containing  serum,  contain  pus. 
As  in  the  vesicular  type,  the  same  dis- 
position to  the  rupture  of  the  pustules  is 
observed,  and  there  is  often  a  tendency 
to  develop  into  the  type  known  as  eczema 
rubrum.  More  or  less  crusting  is  usually 
a  conspicuous  feature.  The  ill-nourished 
and  strumous  persons  are  its  most  com- 
mon subjects.  The  type  is  essentially 
chronic. 

The  squamous  type  of  eczema,  or  ec- 
zema squamosum,  is  a  clinical  variety 
frequently  met  with,  characterized  by 
redness,  infiltration,  and  more  or  less 
scaliness,  with,  especially  when  about  the 
joints,  more  or  less  Assuring.  The  itch- 
ing is  variable,  sometimes  intense,  and 
at  other  times  slight.  This  variety  is 
usually  a  development  from  the  ery- 
thematous or  papular  types,  and,  like 
other  types  of  the  disease,  is  persistent 
and  chronic. 

Eczema  rubrum,  the  oozing  type  of 
eczema,  or  somewhat  dry,  raw-looking 
type  of  eczema,  usually  results  from  a 
pre-existing  vesicular  or  pustular  eczema. 
It  is  characterized  by  a  red,  weeping,  ooz- 
ing, raw-looking  surface,  with  more  or 
less  infiltration  of  the  cutaneous  tissues. 
In  some  cases  there  is  a  combination  of 


weeping  raw  surface  with  crusted  areas. 
In  other  cases  the  weeping  nature  of  the 
disease  is  a  conspicuous  feature,  crusting 
scarcely  having  time  to  form:  eczema 
madidans.  Its  most  frequent  sites  are 
the  face  and  scalp  of  children  and  the 
legs  of  adults;  in  the  latter  in  those  espe- 
cially advancing  in  years.  In  these  cases 
of  eczema  of  the  lower  legs  varicose  veins 
are  often  present  as  a  precursory  and 
concomitant  condition.  It  is  essentially 
chronic,  showing  little,  if  any,  disposi- 
tion to  disappear  spontaneously,  al- 
though it  may  be  somewhat  variable. 
The  degree  of  inflammation  varies  from 
time  to  time. 

The  fissured  type  of  eczema,  or  eczema 
fissum  or  eczema  rimosum,  is  that  type  of 
eczema  in  which  cracking  or  fissuring  of 
the  skin  is  the  most  conspicuous  feature. 
It  is  common  about  the  joints,  especially 
about  the  fingers,  and  in  most  cases  is  a 
part  of  an  apparently  slight  erythema- 
tous eczema.  Fissuring  may  occur  in  any 
type  of  the  disease,  especially  when  about 
the  joints;  but  in  most  cases  it  is  but 
slight  in  character.  It  is  a  persistent 
tj'pe  of  the  disease,  usually  disappearing 
in  part  or  more  or  less  completely  in 
warm  weather.  A  somewhat  analogous 
or  allied  variety  of  eczema  is  the  so-called 
crackled  eczema.  This  is  usually  a  mild 
subacute  erythematous  eczema,  involving 
large  regions  or  the  entire  surface, 
numerous  superficial  cracks  through  the 
upper  epiderm  showing  over  the  fissured 
surface. 

Eczema  sclerosum  and  eczema  verru- 
cosum  are  somewhat  rare  varieties  of  the 
disease.  These  types  are  usually  seen 
about  the  ankles,  lower  leg,  or  feet.  They 
commonly  result  from  a  pre-existing 
papular  eczema.  In  many  respects  these 
types  are  analogous  in  their  symptom- 
atolog}-:  there  is  considerable  thickening 
and  board-like  hardness,  with,  as  a  rule. 


€38 


ECZEMA.    SYMPTOMS. 


much  infiltration,  but  with  the  inflam- 
matory element  slight  or  comparatively 
so.  The  surface  is  roiigh,  hard,  and 
somewhat  horny  to  the  feel,  and  in  the 
verrucous  variety  there  is  added  to  these 
several  symptoms  a  variable  degree  of 
papillary  hypertrophy,  the  surface  hav- 
ing a  distinctly-warty  appearance.  Both 
types  are  essentially  chronic  and  rebell- 
ious to  treatment,  demanding  the  strong- 
est application. 

Infantile  Eczema. — The  disease  is 
common  in  infants  and  young  children. 
It  is  unusual,  comparatively  speaking,  in 
children  past  the  age  of  6.  Even  in  those 
cases  in  which  the  disease  begins  in  the 
first  or  second  year  and  is  persistent,  it 
tends  to  decline  spontaneously  toward 
the  age  of  5  or  6,  or  even  earlier;  or  at 
least  at  this  period  it  will  usually  respond 
rapidly  to  any  mild  or  indifferent  appli- 
cation. The  disease  presents  no  special 
characteristics  in  the  young,  except  that 
in  the  majority  of  such  cases  the  inflam- 
matory element  is  apt  to  be  more  marked. 
In  by  far  the  larger  proportion  of  cases 
the  face  or  the  face  and  scalp  are  the 
seat  of  the  disease;  eczema  of  the  region 
of  the  genitalia  and  anal  cleft  is  also  not 
infrequent. 

All  cases  of  infantile  eczema  will 
usually  do  well  under  treatment,  al- 
though a  disposition  in  many  cases  is 
shown  toward  relapse  till  the  age  of  4  to 
6  is  reached. 

In  eczema  in  infants  and  young  chil- 
dren occurring  about  the  legs  and  arms, 
usually  as  a  vesico-papular  or  papular 
eruption,  discrete  and  patchy,  the  dis- 
ease is  often  obstinate, — much  more  so, 
as  a  rule,  than  in  those  cases  where  the 
disease  is  limited  to  the  face  or  face  and 
scalp.  The  vesicular,  vesicular-papular, 
and  moist  or  crusted  inflammatory  type 
— eczema  nibrum — seem  most  frequent 
in  the  young. 


Eegional  Eczema. — It  is  usual  to  de- 
scribe eczema  as  it  appears  upon  difl'erent 
regions,  as,  for  instance,  the  hands,  face, 
scrotum,  legs,  etc.;  but  the  disease  in 
reality  difl'ers  little,  certainly  not  materi- 
ally, as  it  occurs  upon  different  parts. 
The  description  of  the  several  types  of 
the  disease  as  already  given  suffices. 

It  is  noted  that  the  most  common  seats 
for  eczema  in  those  of  the  active  age,  be- 
tween 21  and  50,  is  about  the  hands,  less 
freqttently  about  the  face  or  the  scalp; 
the  scrotum  is  not  an  uncommon  site, 
and  also  the  anal  region. 

There  is  a  remarkably-obstinate  form 
of  clironie  eczema,  whicli  attacks  the 
palms,  and,  thougli  more  rarely,  the  soles 
sometimes  also.  The  disease  commonly 
takes  its  origin  in  the  centre  of  one 
palm,  though  it  is  generally  not  long 
until  both  are  implicated.  There  are 
hard,  sca-ly  patches  of  infiltrated  skin, 
involving  more  or  less  of  the  surface; 
there  is  ragged  and  uneven  scaling,  while 
in  the  natural  lines  of  flexion,  or  inde- 
pendent of  these,  are  deep  and  painful 
cracks.  The  hands  feel  hot,  and  burn 
and  itch  at  times.  This  morbid  condi- 
tion advances  sometimes  along  the  fingers 
toward  their  tips,  the  pulp  remaining, 
as  a  rule,  immune.  A  symptom  ob- 
served in  the  feet  which  is  not  so  evi- 
dent on  the  palms  is  the  existence  of  a 
band  of  congestion  beyond  the  scaly  area, 
fading  imperceptibly  into  the  natural 
tint  of  sound  skin.  Though  met  with 
in  both  sexes,  this  variety  of  eczema  is 
most  commonly  encountered  in  women, 
and  in  them  about  the  menopause. 
Janiieson  (Edinburgh  Med.  Jour.,  Jan., 
'98). 

In  a  recent  analysis  of  10,000  mis- 
cellaneous skin  cases  in  the  writer's  pri- 
vate practice,  32.01  per  cent,  suffered 
with  eczema.  Neurotic  eczema  is  fre- 
quently observed  in  infancy,  in  connec- 
tion with  cutting  of  the  teeth;  in  child- 
hood it  is  less  common;  its  most  fre- 
quent time  of  occurrence  is  between  20 
and  55  years  of  age.  Various  forms  or 
phases  of  nerve  disturbance  are  seen 
in  connection  with  neurotic  eczema,  and 


ECZEMA.     GEXKliAL  SVilPTOMATOLOGV.     ETIOLOGY. 


639 


they  may  be  considered  under  the  fol- 
lowing heads:  (1)  neurasthenia,  or 
nerve-exhaustion;  (2)  nervous  and 
mental  shock;  (3)  reflex  phenomena 
(o)  of  internal  origin  or  (6)  peripheral; 
(4)  neuroses,  (a)  structural  or  (6)  func- 
tional. 

The  eruption  is  apt  to  come  first  upon 
the  hands  and  face,  less  commonly  on  the 
feet.  But  from  its  starting-point  it  may 
extend  over  large  surfaces.  Neurotic 
eczema  upon  the  hands  is  very  apt  to 
exhibit  vesicles;  but  on  the  adult  face 
the  eruption  is  quite  as  likely  to  as- 
sume and  maintain  the  erythematous 
form,  with  vesicles,  and  often  without 
moisture,  unless  scratched.  The  groups 
of  lesions  have  a  tendency  to  be  pretty 
sharply  defined,  in  more  or  less  her- 
petic patches,  which  may  present  mainly 
solid  papules,  or,  when  torn,  a  raw  sur- 
face. It  is  intensely  itchy,  and  the 
spasms  of  itching  are  sometimes  fearful 
and  utterly  uncontrollable.  L.  Duncan 
Bulkley  {.Jour.  Amer.  Med.  Assoc,  Apr. 
16,  '98). 

In  eczema  about  the  finger-nails  the 
matrix  or  the  bed  of  the  nail  may  be 
affected,  primarily,  or  by  contiguity 
from  eczema  on  the  back  of  the  finger. 
The  first  sign  is  the  redness  of  the 
supra-ungual  tissue,  which  becomes 
painful  to  pressure.  Rarely,  so  much 
serum  may  exude  that  the  nail  is  lifted 
up,  and  finally  falls  off.  Striations  are 
noted  in  the  nails,  with  punetiform  de- 
pressions. The  whole  nail  may  be 
raised  from  its  bed  or  a  depression  may 
appear  in  the  median  line.  If  the  ec- 
zema is  chronic  the  nails  will  be  de- 
formed. W.  Dubreuilh  and  D.  Freche 
(Jour,  de  M(5d.  de  Bordeaux,  Apr.  14, 
1901). 

In  those  past  the  age  of  50  the  most 
common  site  is  the  lower  leg,  although 
eczema  of  the  face  is  not  infrequently 
met  with. 

General  Symptomatology. — The  sub- 
jective symptoms  in  eczema  are  itching, 
burning,  and  a  sensation  of  heat.  These 
may  be  .severally  present,  or,  as  is  more 
commonly  the  case,  one  is  predominant. 
The  degree  varies,  sometimes  slight  and  ' 


at  other  times  almost  unbearable.  As  a 
rule,  there  are  no  constitutional  symp- 
toms so-called  in  eczema  cases.  In  ex- 
tensive general  acute  eczema  there  may 
be  slight  febrile  action  and  sometimes 
slight  chilliness  at  the  outbreak  of  the 
attack.  The  degree  of  inflammatory  ac- 
tions varies  in  the  same  case  from  time 
to  time  and  in  different  cases.  The  dis- 
ease may  be  acute  both  in  type  and  ita 
course,  running  to  an  end  in  several 
weeks  or  one  or  two  months.  As  a  rule, 
however,  whatever  the  type  of  the  in- 
flammatory process — acute,  subacute,  or 
chronic — the  disease  is  persistent  and 
long-continued,  with,  in  most  cases, 
little,  if  any,  tendency  to  disappear  spon- 
taneously. Seasons  often  have  an  influ- 
ence, the  disease  usually  being  less  active 
or  partly  or  completely  disappearing  in 
the  summer  weather.  On  the  other  hand, 
there  are  cases  of  the  disease  met  with 
that  are  at  their  worst  in  summer  time, 
and  frequently  disappear  in  the  colder 
weather;  such  instances  are,  however, 
exceptional. 

Etiology. — The  consensus  of  opinion 
points  to  both  external  and  constitu- 
tional causes  as  active  factors  in  most 
cases  of  the  disease.  The  possibility  and 
even  probability  of  this  disease's  being 
due  to  a  parasite  is  more  or  less  seriously 
entertained  in  some  quarters. 

In  eczema  the  staphylococcus  aureus 
present  in  practically  pure  culture  in  a 
large  series  of  examined  cases  and  in- 
vaded the  deeper  layers  of  the  skin.  Ec- 
zema may  therefore  be  considered  to  be 
due  to  a  staphylococcic  infection.  W. 
Seholtz  (Deutsche  mcd.  Woch.,  Julv  26, 
1900). 

In  some  ordinary  forms  of  eczema 
efflorescences  appear  which  contain  no 
micro-organisms  or  some  the  pathogenic 
nature  of  which  is  not  demonstrable.  In 
such  cases  the  etiology  depends  probably 
upon  mechanical  or  chemical  irritation. 
In  other  cases  ordinary  streptococci   or 


640 


ECZEMA.    ETIOLOGY. 


staphylococci  are  seen  which  can  be  ob- 
served at  any  time  in  any  portion  of  the 
healthy  skin.  These  bacteria,  invading 
the  skin  where  there  is  an  eczema,  may 
arouse  additional  inflammation,  the  se- 
verity of  which  depends  upon  the  pa- 
tient's idiosyncrasy  and  the  virulence  of 
the  germs.  Jadassohn  ("Wiener  med. 
Blatter,  Aug.  23,  1900). 

Bacteriological  studies  of  74  cases  of 
this  disease  showed  23  types  of  coccus. 
Absolutely  typical  eczematous  lesions 
were  produced  by  two  of  these:  the 
diclimactericus  eczematis  albus  flavens 
and  monoclimaetericus  eczematis  vives- 
cens,  while  a  third  strongly  suspicious 
form  might  be  called  triclimactericus 
eczematis  tenuis.  P.  G.  Unna  (Wiener 
klin.  Eund.,  Sept.  16,  1900). 

Gilchrist  and  Sabouraud  have  noted 
the  frequency  with  which  streptococci 
occur  in  skin  lesions.  Personal  method 
by  which  it  was  possible  to  detect  small 
numbers  of  this  organism.  Sabouraud's 
medium  is  used  and  inoculated  by  means 
of  a  long  capillary  tube  from  which  the 
fluids  or  crusts  to  be  investigated  are 
aspirated.  In  more  than  100  cases  it 
was  possible  to  detect  staphylococci  in 
53.7  per  cent.;  27  of  these  cases  were 
eczema,  and  in  these  streptococci  were 
present  17  times.  In  order  to  deter- 
mine in  what  proportion  of  normal 
skins  streptococci  were  present,  160 
areas  in  55  human  beings  were  studied, 
and  streptococci  were  found  in  7.5  per 
cent.  They  are  most  frequent  in  the 
axilla  and  on  the  back.  These  strepto- 
cocci resemble  exactly  those  found  in 
skin  lesions.  The  artificial  forma  of 
dermatitis  are  sometimes  sterile,  and 
sometimes  bacteria  in  considerable  num- 
bers can  be  obtained  from  them.  Fred- 
eric (Mlincliener  mod.  \Voclien.,  No.  38, 
1901). 

Among  the  constitutional  influences 
which  are  or  seem  to  be  of  some  impor- 
tance as  predisposing  or  active  factors  are 
gout,  rheumatism,  disorders  of  digestion 
or  assimilation,  dentition,  struma,  gen- 
eral debility,  and  loss  of  nervous  tone. 

Importance  of  the  vital  relations  of 
the  cclI-protopla«m  in  the  epithelial  ccIIb, 


and  of  the  cellular  secretions  or  excre- 
tions in  destroying  noxious  agencies,  on 
the  one  hand,  and  promoting  the  health 
of  the  tissues,  on  the  other,  are  in 
danger  of  being  overlooked,  in  conse- 
quence of  the  long  discussions  wliich 
take  place  concerning  the  bacteriology 
of  eczema,  many  of  which  are  unsup- 
ported by  exact  observations  or  bac- 
teriological research  of  any  sort.  Les- 
lie Roberts  (Brit.  Jour,  of  Derm.,  Jan. 
and  Feb.,  '99). 

ilany  Fi-encli  clinicians  regard  eczema 
as  being  due  to  internal  causes,  among 
which  digestive  functions  play  an  ex- 
tremely important  rOle.  Series  of  in- 
vestigations into  the  chemical  charac- 
ters of  the  gastric  contents  in  such 
cases,  with  a  view  to  finding  additional 
evidence  in  support  of  this  proposition. 
In  almost  all  cases  he  finds  disordered 
absorption  and  deficient  motility.  The 
gastric  juice  also  shows  hypo-acidity, 
hydrochloric  acid  being  reduced  in 
amount.  In  many  instances  there  is 
dilatation,  while  absorption  is  consid- 
erably prolonged.  Abnormal  fermenta- 
tions were  a  striking  feature  in  hia 
cases,  producing  excess  of  lactic,  butyric, 
and  acetic  acids.  The  prevalence  of  such 
gastric  disturbances  the  author  consid- 
ers should  be  borne  in  mind  in  all  eases 
of  eczema,  in  order  that  general  treat- 
ment may  be  employed  as  well  aa  the 
local  methods  indicated  for  the  skin. 
This  also  points  to  the  importance  of 
dietary,  not  only  to  reduce  the  tendency 
to  abnormal  fermentation,  but  also  to 
obviate  any  arthritic  complication,  for, 
as  is  well  known,  eczematous  conditions 
often  accompany  gouty  symptoms.  It 
is  quite  possible  also  that  certain  indi- 
vidual peculiarities  of  digestion  or  ab- 
sorption may  have  to  be  counteracted, 
as  there  is  a  certain  amount  of  evidence 
to  show  that  the  ingestion  of  certain 
articles  of  food,  such  as  game,  spiced 
and  very  salt  articles  of  diet,  etc.,  may 
be  the  immediate  cause  of  an  attack  of 
eczema.  Mcynet  (These  de  Lyon,  1901; 
Brit.  Med.  Jour.,  Jan.  11,  1902). 

For  a  time  tho  idea  of  a  pathogenic 
microbe  of  eczematous  eruptions,  so 
strongly  advocated  l)y  Unna,  seemed  to 


ECZEMA..    PATHOLOGICAL  ANATOMY.    DIAGNOSIS. 


641 


account  for  tlicm,  but  unfortunately  tliis 
theory  has  not  been  confirmed  by  pre- 
cise observations,  and  must  be  aban- 
doned, at  least  provisionally.  But  if  we 
apply  ourselves  to  the  clinical  analysis 
of  facts,  we  perceive  that  true  eczema- 
tous  eruptions  arise  now  in  consequence 
of  extenial  irritations,  again  from  vari- 
ous into.\ication3,  autointo.\ications,  or- 
ganic diseases,  nervous  shocks,  etc.  The 
most  divergent  causes  appear  to  possess 
the  power  of  evoking  them.  We  are  dis- 
posed for  the  moment  to  view  true  vesic- 
ular eczema  as  a  pure  cutaneous  reac- 
tion. Brocq  (Ann.  de  dermat.  et  do 
syphil..  Mar.,  1003). 

Immoderate  habits  in  the  use  of  cer- 
tain foods,  drinks,  and  drugs  also  in- 
directly or  directly  have  an  influence, 
such  as  alcoholic  drinks,  narcotic  drugs, 
and  excessive  tea-  or  cofEee-  drinking. 

Overwork,  especially  of  a  mental  char- 
acter, in  those  of  hereditary  eczematous 
tendency  will  often  be  provocative  of  an 
attack.  That  the  hereditary  disposition 
to  the  disease  exists  in  many  families 
cannot  be  denied. 

Among  the  external  exciting  factors 
may  be  mentioned  cold  and  heat,  espe- 
cially the  former;  sharp,  biting  winds; 
and  too  liberal  use  of  certain  soaps;  the 
handling  of  dyestuffs,  chemical  irritants, 
and  the  like;  vaccination,  and  exposure 
to  certain  plants.  Having  the  hands  fre- 
quently in  water,  as  with  washerwomen, 
the  handling  of  sugar  and  flour,  and  re- 
peated antiseptic  cleansing  of  the  hands 
often  bring  about  the  various  conditions 
of  eczema  of  these  parts  known  respect- 
ively under  the  names  of  washerwomen's 
itch,  baker's  itch,  and  grocer's  itch,  and 
surgeon's  eczema.  So  far  as  known  the 
disease  does  not  possess  contagious  prop- 
erties, and  in  a  disease  so  frequent  as  this 
if  such  existed  it  would  have  been  clearly 
demonstrated. 

In  some  cases  of  markedly  inflamma- 
tory eczema,  especially  when  of  the  pus- 


tular type,  swelling  of  the  neighboring 
lymphatic  glands  is  noticed,  but  this 
rarely  leads  to  suppurative  change,  the 
swelling  and  pain  disappearing  as  soon 
as  the  inflammatory  symptoms  have 
abated.  In  some  cases  of  eczema  a  con- 
dition of  f  urunculosis  is  occasionally  ob- 
served. 

Pathological  Anatomy. — Eczema  is  es- 
sentially a  catarrhal  inflammation  of  the 
skin,  and  is  seated  chiefly  in  the  rete  and 
papillary  layer;  in  long-continued  and 
severe  cases  the  lower  part  of  the  corium 
and  even  the  subcutaneous  tissue  may  be 
more  or  less  involved,  but  never  destruct- 
ively. Hyperaemia  and  exudation  are  to 
be  found  in  all  cases,  either  as  punctate, 
localized,  or  more  or  less  diffused.  The 
vascular  changes  are  the  same  as  ob- 
served in  all  inflammations. 

Diagnosis. — Eczema  is  to  be  distin- 
guished chiefly  from  erysipelas,  psoriasis, 
seborrhcEa,  sycosis,  scabies,  and  ring- 
worm. 

Erysipelas. — Markedly  acute  eczema 
about  the  face  sometimes  presents  early 
in  the  course  of  the  attack  a  resemblance 
to  erysipelas,  but  in  the  latter  disease  the 
border  is  sharply  defined  and  elevated;  it 
usually  starts  from  one  point  and  spreads 
rapidly,  and  is  accompanied  by  systemic 
symptoms  of  more  or  less  violence. 

Psoriasis  as  commonly  met  with  is 
not  difficult  to  differentiate.  The  numer- 
ous, variouslj'-sized,  sharply-defined  scaly 
patches,  of  general  distribution,  of  psori- 
asis make  this  disease  sufficiently  char- 
acteristic. The  face  and  hands  are  rarely 
involved,  or  only  to  a  slight  extent,  at 
least,  in  psoriasis,  while  these  regions  are 
favorite  sites  for  eczema.  The  psoriasic 
eruption  often  is  seen  most  markedly  on 
the  extensors  of  the  arms  and  legs,  espe- 
cially about  the  elbows  and  knees;  ec- 
zema is  more  common  in  the  flexures. 
Psoriasis  is  usually  markedly  scaly,  ec- 


642 


ECZEMA.    PROGNOSIS. 


zema  rarely  so.  In  occasional  instances 
psoriasis  is  limited  to  the  scalp,  appear- 
ing here  as  several  or  niimerous  vari- 
ously-sized scaly  areas,  resembling 
squamous  eczema  of  this  part.  The 
same  differential  characters  can  be  here 
recognized,  if  the  case  is  studied,  as  when 
seated  upon  other  parts.  Moreover,  a 
careful  examination  ■«ill  usually  disclose 
the  presence  of  several  small  or  mod- 
erately sized  characteristic  psoriasic 
patches  on  the  limbs,  especially  about 
the  elbows  and  knees.  Eczema  of  the 
scaly  type  is  usually  seated  upon  one 
region,  is  rarely  generalized  in  its  dis- 
tribution, and  the  area  or  areas  are  rarely 
sharply  defined.  Itching  is  the  rule  in 
eczema  and  is  often  absent  or  slight  in 
psoriasis.  In  many  cases  of  chronic  scaly 
eczema  there  is  often  a  history  of  gummy 
oozing  which  does  not  obtain  in  psoriasis. 
The  eruption  produced  in  the  parasitic 
disease  scabies  and  pediculosis  is  essen- 
tially eczematous  in  many  of  its  char- 
acters, but  is  usually  multiform,  consist- 
ing of  papules  and  pustules,  the  latter 
often  being  large  in  size.  The  distribu- 
tion of  the  eruption  in  these  parasitic 
diseases  will  often  be  sufficiently  char- 
acteristic, and  suspicion  may  be  con- 
firmed by  the  finding  of  the  pediculus  in 
pediculosis  or  by  the  burrow  in  scabies. 
Seborrhoea  at  times  bears  close  resem- 
blance to  a  mild  eczema,  more  especially 
as  it  occurs  on  the  scalp.  The  sebor- 
rhosic  disease  is,  however,  rarely  inflam- 
matory, except  accidentally  so;  the  scales 
are  greasy,  and  there  is  lack  of  infiltra- 
tion and  thickening. 

Sycosis. — Eczema  of  the  bearded  face 
may  be  mistaken  for  sycosis,  but  this 
latter  disease  is  essentially  one  of  the 
hair-follicles  —  folliculitis  barba;  —  and 
limited  to  the  hairy  region  of  the  face, 
and  is  rarely  itchy.  Eczema,  on  the 
other  hand,  is  seldom  limited  to  this 


region,  but  extends  on  to  the  non-hairy 
parts  of  the  face,  is  not  follicular,  and  is 
very  itchy.  Eingworm  can  scarcely  be 
confounded  with  eczema,  as  eczema  is 
seldom  sharply  defined,  rarely  ring- 
shaped,  but  is  diffused,  with  no  tendency 
to  clear  up  in  the  centre.  In  cases  of  a 
doubtful  character  microscopical  exam- 
ination of  the  scales  will  be  sure  to  differ- 
entiate. 

Dermatitis.  —  Dermatitis  is  some- 
times with  difficulty  distinguished  from 
eczema,  as  the  symptoms  of  mild  derma- 
titis are  essentially  the  same  as  those  of 
eczema;  in  fact,  these  cases  may  be 
looked  tipon  as  artificial  eczemas.  Ec- 
zema rarely,  if  ever,  shows  large  vesicle- 
or  bleb-  formation  as  found  in  the  severe 
types  of  dermatitis,  more  particularly 
from  rhus.  The  history  of  the  case  will  , 
often  throw  light  upon  the  diagnosis.  In 
those  eczematously  inclined,  however, 
what  may  be  a  true  artificial  dermatitis 
in  the  beginning  may  terminate  in  a  veri- 
table stubborn  eczema. 

Among  other  diseases  that  should  not 
be  confounded  may  be  mentioned  rosa- 
cea, erythema,  urticaria,  herpes  zoster, 
lichen  planus,  lichen  ruber,  and  impetigo 
contagiosa. 

Prognosis. — Eczema,  while  often  most 
intractable,  cannot  be  said  to  be  incur- 
able. It  may  recur  like  any  other  dis- 
ease to  which  a  person  may  be  prone. 
Under  favorable  circumstances  mild 
cases  yield  quite  readily.  During  the 
course  of  treatment  the  disease  may 
show  slight  relapses,  but  each  succeeding 
one  is  usually  noted  to  be  of  a  milder  and 
less  obstinate  character.  It  is  difficult,  in 
the  individual  case,  to  state  an  opinion, 
especially  as  to  the  duration  of  treat- 
ment. Several  factors  should  influence 
the  prognosis:  the  extent  involved,  the 
duration,  previous  variability,  the  nature 
of  the  exciting  and  predisposing  causes, 


ECZEilA.    TREATMENT. 


G43 


and  whether  these  can  be  readily  man- 
aged, and,  finally,  and  of  great  impor- 
tance, the  care  and  attention  the  patient 
gives  to  the  carrying  out  of  the  treat- 
ment advised. 

Treatment. — There  has  been  great  di- 
versity of  views  as  to  the  methods  of 
treatment, — e.g.,  as  to  whether  it  should 
be  external  or  constitutional.  The  con- 
servative course,  and  that  which  seems 
to  give  the  best  results,  is  that  which 
places  reliance  upon  conjoint  local  and 
systemic  measures.  It  is  not  improbable 
that  there  are  some  cases  met  with  which 
persist  without  any  constitutional  cause, 
or  the  latter  has  already  disappeared,  and 
in  such  instances  external  treatment 
alone  will  bring  about  permanent  relief. 
There  are  certain  general  or  hygienic 
measures  which  should  receive  attention. 
The  diet  should  be  plain,  but  nutritious, 
all  fancy  dishes  and  indigestible  meats 
and  foods  being  avoided  as  much  as  pos- 
sible. 

It  is  very  important  to  watch  the 
digestive  functions  and  the  action  of 
the  kidneys  in  all  forms  of  eczema.  The 
diet  is  also  very  important,  and  in 
the  majority  of  cases  proper  food  is  the 
most  efficacious  internal  remedy.  The 
diet  should  be  based  somewhat  upon  the 
diathesis  of  the  patient,  but  it  mainly 
consists  in  the  prohibition  of  all  alco- 
holic beverages  save  a  small  quantity  of 
wine  with  a  little  water.  Cofl"ee  and  tea 
are  diminished  in  quantity;  fish,  crabs, 
clams,  and  oysters  may  be  given  in  pref- 
erence to  red  meats.  The  patient  is  not 
allowed  to  take  asparagus  or  cucumbers. 
Eggs,  milk,  and  other  light  articles  of 
diet  are  exceedingly  useful.  All  fer- 
mented drinks  are  absolutely  prohibited, 
and  also  all  acid  fruits.  BaiTazzi  (Re^nie 
de  Thi'rap.  Jledico-Chir.,  June  1,  '90). 

Treatment  includes  both  constitutional 
and  local  measures.  The  diet  must  al- 
ways be  carefully  directed,  and.  for  the 
purpose  of  furnishing  best  possible  nerve- 
nutriment,  an  increase  in  the  digestible 
fatty  matter  and  phosphates  should  be 


ordered.  Some  caution  may  be  required 
in  regard  to  the  former,  but  with  a  little 
care  the  amount  of  fat  of  meats  and  oils, 
and  also  fresh  butter,  can  be  added  to 
tlie  dietary.  The  phosphates  are  found 
abundantly  in  the  preparations  of  whole 
wheat,  such  as  eruslied  wheat,  wheat- 
ena,  wheatlets,  wheat-germs,  Pettijohn's 
breakfast-food,  etc.,  as  also  in  bread 
made  from  the  whole  wheat-flour,  some 
of  which  should  be  taken,  if  possible, 
three  times  daily.  Jlilk,  however,  if 
properly  taken,  proves  of  the  most  signal 
advantage.  It  should  be  taken  wann, 
pure,  and  alone,  one  hour  before  each 
meal,  and  also  at  bed-time,  if  sufficient 
time  has  elapsed  for  the  stomach  to  be 
perfectly  empty,  which  is  at  least  four 
hours  after  a  hearty  meal.  This  pre- 
cludes the  possibility  of  adding  liquor 
or  eggs  to  the  milk,  and  especially  should 
there  never  be  a  cracker  or  anything 
else  eaten  with  or  near  it.  The  indica- 
tions for  local  treatment  differ  materially 
in  different  cases.  L.  Duncan  Bulkley 
(Jour.  Amer.  .Med.  Assoc,  Apr.  10,  '98). 
Pork  and  salted  meats,  veal,  pastries, 
strong  acids  or  acid  fruits,  gravies, 
cheese,  sauces,  condiments,  etc.,  and  the 
excessive  drinking  of  tea  or  coffee  are 
to  be  eschewed.  Beer,  wine,  and  spirits 
are  also  to  be  avoided. 

Out-door  life  is  to  be  commended  in 
suitable  weather,  and  exercise,  especially 
systematic  in  character,  are  of  great 
value. 

As  to  constitutional  remedies,  it  may 
be  said  that  there  are  no  specifics,  al- 
though arsenic  seems  at  times  of  special 
value  in  chronic,  sluggish,  papular,  and 
erythemato-squamous  types.  Each  case 
must  be  carefully  studied,  and  the  pre- 
disposing factor  or  factors,  if  possible, 
discovered,  and  the  treatment  suitable 
instituted.  When  the  itching  is  so  in- 
tense as  to  prevent  sleep,  recourse  may  be 
had  to  the  bromides,  phenacetin.  chloral, 
sulphonal.  trional.  and  the  like;  opiates 
are  apt  to  cause  aggravation. 

If  pruritus  is  present  an  absolute  milk 
diet    must    be    ordered.      Xo    medicine 


644 


ECZEMA.    TREATMENT. 


should  be  given  until  the  case  has  been 
under  observation  for  some  time,  since 
there  are  few  drugs  which  may  not  in- 
crease pruritus.  The  urine  must  be  ex- 
amined for  uric  acid,  sugar,  albumin, 
oxaluria,  phosphaturia,  and  peptonuria, 
and  the  patient's  organs  and  functions 
thoroughly  overhauled.  The  most  harm- 
less cutaneous  antispasmodics  are  asa- 
fcetida  and  musk  in  doses  up  to  30 
grains,  and  valerian  in  various  forms. 
Opium  is  generally  contra-indicated,  be- 
ing itself  a  frequent  cause  of  pruritus. 
For  the  insomnia,  sulphonal  or  trional 
in  doses  up  to  30  grains  in  twenty-four 
hours  is  much  surer  and  generally  well 
borne  by  the  skin.  Arsenic  is  useful  in 
chronic  cases,  but  does  not  suit  acute 
cases  or  chronic  during  subacute  ex- 
acerbations, with  the  exception  of  some 
varieties  limited  to  the  extremities  or 
the  head.  In  cases  with  a  gouty  diath- 
esis, bicarbonate  of  sodium  acts  well. 
The  dose  must  be  moderate  if  given  for 
a  long  time.  Sulphur  in  small  doses  is 
very  useful  with  young  anaemic,  "lym- 
phatic," or  tuberculous  patients.  It  is 
contra-indicated  in  neurotic  or  cardiac 
cases,  or  when  the  eczema  is  recent  and 
acute.  It  is  best  given  as  natural  sul- 
phur-waters. Besnier  (La  Belgique  M6d., 
May  6,  '97). 

In  the  attempt  to  get  relief  from  the 
itching,  which  can  seldom  be  obtained 
by  local  measures  alone,  the  plan  of 
treatment  should  be  a  soothing  and  pro- 
tective one.  Zinc  ointment  with  1  or  2 
per  cent,  of  carbolic  acid  or  creasote,  or 
with  5  to  10  per  cent,  of  ichthyol,  or 
tincture  of  camphor,  is  always  a  safe 
and  generally  beneficial  dressing,  but  to 
be  of  service  it  should  be  kept  thickly 
applied,  spread  on  lint  in  moist  places, 
and  bound  on  firmly.  In  the  acutely 
inflamed,  and  especially  in  the  erythem- 
atous forms  of  the  eruption,  there  is 
nothing  better  than  the  well-known  cal- 
amin  and  zinc  lotion,  freely  sopped  on 
many  times  in  the  day.  In  the  ery- 
thematous eczema  of  the  face  a  tannin 
ointment,  'A  to  1  drachm  to  the  H 
drachms,  with  2  per  cent,  of  carbolic 
acid,  is  cfTcctive.  The  use  of  very  hot 
water  for  a  brief  application,  followed 
by     an     appropriate     ointment,     should 


never  be  forgotten.  In  old  cases  of 
eczema  of  the  scrotum  the  effect  of  this 
treatment  is  sometimes  very  remarkable. 
L.  Duncan  Bulkley  (Jour.  Amer.  Med. 
Assoc,  Apr.  lU,  'OS). 

In  the  chronic  eczema  of  infants  good 
results  have  been  obtained  from  the  in- 
ternal administration  of  arsenic;  1  drop 
of  a  mixture  of  equal  parts  of  Fowler's 
solution  and  distilled  water  may  be  given 
in  milk  after  the  midday  meal,  and 
gradually  increased  to  6  or  7  drops  to 
infants  of  two  j'ears  and  over.  In  suck- 
lings and  infants  under  two  years  of  age, 
1  drop  of  Fowler's  solution  of  the 
strength  of  1  in  3,  gradually  increased 
to  5  drops,  may  be  given.  The  treat- 
ment usually  lasts  si.xteen  or  eighteen 
weeks.  Neuberger  (Archiv  f.  Derm.  u. 
Syphilis,  vol.  xlvii,  '99). 

In  chronic  eczema  the  itching  can 
often  be  allayed  by  the  use  of  bran- 
baths,  one  being  taken  each  night.  The 
water  in  which  bran  has  been  boiled 
can  be  poured  into  a  long  bath,  and  hot 
water  can  be  added  until  a  temperature 
of  95°  to  98°  F.  has  been  reached,  or  if 
the  patient  has  not  such  a  bath  a  wash- 
ing basin  filled  with  the  bran-water  can 
be  used.  Such  a  bath  or  sponging  adds 
enormously  to  the  comfort  of  patients, 
and  by  diminishing  the  tendency  to 
scratch  indirectly  helps  to  a  cure.  R. 
M.  Simon  (Birmingham  Med.  Review, 
Feb.,    1900). 

Among  the  tonics  that  are  often  of 
value  may  be  mentioned  codliver-oil, 
hypophosphites,  quinine,  nux  vomica, 
the  vegetable  bitters,  iron,  arsenic,  and 
manganese.  Arsenic  should  never  be 
given  in  the  acute  type,  or  in  any  case 
in  which  the  disease  is  of  the  spreading 
or  active  character.  Among  alkalies, 
especially  useful  in  gouty  and  rheumatic 
cases,  may  be  mentioned  sodium  salic- 
ylate, potassium  bicarbonate,  sodium 
bicarbonate,  and  the  lithium  salts. 

Case  of  eczema  of  scalp  in  a  man  of 
rheumatic  tendencies,  rheumatism  dis- 
ai)poaring  with  ay)pearance  of  eruption; 
cure  by  salicylic  acid.  C.  E.  Lockwood 
(Universal  Med.  Jour.,  Apr.,  '95). 


ECZEJIA.    TREATMENT. 


645 


Among  alteratives  that  occasionally 
are  resorted  to  may  be  mentioned  calo- 
mel, colchicum,  arsenic,  and  potassium 
iodide.  In  some  cases  rather  free  action 
of  the  kidneys  is  desirable,  and  recourse 
may  be  usually  had  to  potassium  acetate, 
potassium  citrate,  and,  in  exceptional 
cases  of  more  or  less  general  eczema, 
to  the  oil  of  copaiba.  Laxatives  form 
a  very  important  class  in  the  treatment 
of  this  disease,  as  indigestion  with  more 
or  less  active  constipation  is  often  a 
striking  symptom.  The  various  salines, 
and  aperient  mineral  waters,  castor-oil, 
cascara  sagrada,  rhubarb,  and  aloes,  and 
other  vegetable  cathartics  are  useful. 

Eczema  is  probably  an  excretory  in- 
flammation;    object    of    treatment    to 
relieve    skin   by    shifting   the    stress    of 
elimination  to  sound  organs;   in  gouty 
persons  salines  that  act  on  the  bowels 
and    kidneys;    dermatitis    once    started, 
liowever,    becomes    complicated    by    in- 
vasion   of    numerous    micro-organisms; 
hence    mild    local    applications,    creolin 
ointment  ('/=  drachm  to  1  ounce  of  vase- 
lin),  or  a  weak  creolin  lotion  ('/=  drachm 
to  the  pint  of  water)   will  suffice  for  a 
cure.      David    Walsh    {^led.    Press    and 
Circ,  Oct.  23,  ''Jo). 
In  this  class  of  cases  the  several  di- 
gestives and  bitter  tonics  are  often  pre- 
scribed with  advantage,  such  as  pepsin, 
pancreatin,   papoid,   muriatic   acid   and 
gentian,  quassia,  calisaj'a,  and  other  bit- 
ter tonics. 

Arsenic  is  best  given  by  the  mouth  in 
doses  of  Vm  grain  of  acid,  arsen.  lodo- 
thyrin  and  thyroid-gland  tabloids  are 
extremely  valuable  in  some  of  the  ec- 
zemata.  Oiiphorin  is  useful  in  climac- 
teric eczema.  The  internal  treatment  of 
acute  eczema  is  very  unsatisfactory. 
Locally,  the  best  results  are  usually  ob- 
tained by  the  free  application  of  dust- 
ing-powders, during  the  erythematous 
and  early  papular  stages.  Those  are 
zinc,  bismuth,  boro-tannate  of  alu- 
minium, and  dermatol.  For  itching,  a 
lotion  of  thymol  (1  in  400),  acid,  car- 
bolic.  (1  in  50),  and  menthol  spirit   (1 


in  50  to  1  in  lOOj,  may  be  used  under 
the  powder,  care,  however,  being  taken 
not  to  apply  it  to  the  face  or  scrotum. 
In  the  papulo-vesicular  stages,  ordinary 
earth-clay,  \\'ith  from  1  to  2  per  cent,  of 
acetic  acid,  1  per  cent,  of  resorcin,  or  1 
per  cent,  of  thymol,  is  one  of  the  best 
applications.  Lassar's  paste,  turaenol 
paste,  and  thiol  or  ichthyol  paste  are 
also  valuable.  When  the  crusts  form, 
salicylic  acid,  in  a  vehicle  of  olive-oil, 
is  useful,  and  an  especially  good  formula 
is: — 

IJ  Zinci  oxidi,  1  part. 

Bismuth,  subnitrat.,  1  part. 

Unguent.  lenient.,  4  parts. 

Unguent,  simpl.,  4  parts. 
The  squamous  forms,  with  their  al- 
most absent  peeling  processes,  are  to  be 
treated  by  the  tar  preparations.  R. 
Ledermann  (Berliner  klin.  Woch.,  Feb. 
4,  1901). 

External  Treatment, — In  the  local 
management  of  eczematic  cases  soap  and 
water  must  be  used  with  judgment.  In 
the  acute  and  in  many  subacute  cases 
these  cleansing  agents  should  be  em- 
ployed as  infrequently  as  circumstances 
will  permit.    . 

Water  sometimes  not  only  delays  the 
cure,  but  absolutely  prevents  cases  from 
getting  well.  When  it  becomes  neces- 
sary, an  oily  preparation  containing  a 
few  di'ops  of  carbolic  acid  is  to  be  used. 
John  Edwin  Hays  (Pediatrics,  Apr.  15, 
'98). 

In  cleansing  eczematous  surfaces  and 
removing  secondary  products  plain  water 
or  soap  and  water  should  be  avoided,  if 
possible.  If  the  former  has  to  be  era- 
ployed  it  should  be  as  hot  as  can  be 
borne,  and  the  surface  over  which  it 
has  been  used  should  be  dried  quickly 
and  thoroughly  and  the  selected  dress- 
ing immediately  applied.  All  detergent 
fluids  should  be  warmed  before  use. 
Olive-  or  cotton-seed  oil  will  cleanse  al- 
most as  well  as  soap  and  water,  and, 
if  the  part  is  carefully  wiped,  but  little 
preasiness  remains.  Or  thin  strained 
rice-milk  cleanses  well  and  is  soothing 
to  tender  and  acutely-inflamed  surfaces. 
Before  anv  line  of  local  treatment  can 


646 


ECZEMA.     TEEATMENT. 


be  begun  all  secondary  products — crusts, 
scales,  etc. — must  be  removed.  This  can 
be  accomplished  by  saturating  them  with 
oil.  W.  M.  Nelson  ^!^Iont.  Jled.  Jour., 
Apr.,  '9S). 

In  the  treatment  of  periungual  eczema 
boric-acid  or  salicylic-acid  washes  and  a 
dusting-powder  used.  Eesorcin  may 
give  good  results  in  chronic  inflamma- 
tion. W.  Dubreuilh  and  D.  Freche 
(Jour,  de  M6d.  de  Bordeaux,  Apr.  14, 
1901). 

Cleanliness  may  often  be  maintained 
by  gently  rubbing  off  with  cold  cream, 
petrolatum,  or  almond-oil.  Even  in 
such  cases,  however,  occasional  washing 
is  necessary,  both  for  the  sake  of  clean- 
liness and  in  order  to  get  rid  of  the 
products  of  the  disease  and  to  remove  the 
messiness  which  has  resulted  from  the 
applications.  A  remedial  application 
should  always  be  made  immediately  after 
washing  has  been  employed.  In  some 
cases,  especially  those  of  a  chronic  and 
scaly  and  markedly-sluggish  character 
the  use  of  soap  and  water  is  resorted  to 
frequently  and  has  often  a  therapeutic 
value;  indeed,  in  some  such  cases  the 
green  soap — sapo  viridis — may  be  occa- 
sionally or  frequently  used  with  advan- 
tage. 

Notwithstanding  the  nearly  universal 
dictum  of  the  hai-nifulness  of  water, 
the  value  of  baths  containing  tar,  or 
taken  after  the  latter  has  been  well 
painted  over  the  alTeeted  regions,  in- 
sisted upon.  After  this  is  effected  Vene- 
tian talc  is  to  be  copiously  dusted  all 
over  and  around  the  area.  Lassar  (Der- 
matol. Zeitschr.,  B.  2,  H.  (5,  '95). 

A  current  of  steam  of  104°  to  122°  F. 
directed  to  the  affected  parts  of  the  skin 
in  eczema  removes  crusts  and  scales,  oc- 
casions increased  scaling  of  the  epider- 
mis, favors  the  absorption  of  superficial 
and  deeper  infiltrations  of  the  skin,  di- 
minishes or  even  entirely  stops  formation 
of  pus  on  the  surfaces  deprived  of  epi- 
dermis, and  at  the  same  time  produces 
increased  regeneration  of  tissues  where, 
on  account  of  chronic  processes,  the  con- 


ditions for  healing  are  very  unfavorable. 
A    convenient    apparatus   consists    of   a 
thick    copper    cylinder    containing    two 
or  three  glasses,  the  bottom  one  being 
heated   with   an  alcohol-lamp.     On  the 
top  are  two  openings, — one  for  pouring 
in  water   (closed  by  means  of  a  screw) 
and  the  other  for  a  bent  tube.    Accord- 
ing  to  the   sensibility   of  the   skin,  the 
tube  is  kept  three  to  five  inches  from  it. 
The  si'aiwe  lasts  fifteen  to  thirty  min- 
utes.    A.   Liberson    (So.   Russian   Med. 
Gaz.,  Nos.  51,  52,  '95). 
Applications  are  to  be  made  in  ec- 
zema two  or  more  times  daily,  and  when 
possible  the  continuous  application  is  to 
be  advised. 

In  the  selection  of  external  remedies 
for  a  particular  case  common  sense  must 
be  employed.     In  those  cases  in  which 
the  type  of  disease  is  acute  or  subacute 
mild  remedies  are  to  be  used.     In  the 
milder    erythematous    variety    dusting- 
powders  of  zinc  oxide,  talc,  starch,  and 
kaolin  are  soothing  and  beneficial;    they 
may  be  used  alone  or  immediately  follow- 
ing the  application  of  one  of  the  washes 
named  below.    The  conjoint  use  of  black 
wash  or  boric-acid  lotion  with  oxide-of- 
zinc  ointment  or  any  mild  ointment  may 
give  beneficial  results.     Or  the  simple 
oxide-of-zinc   ointment   with   20   to   30 
grains  of  boric  acid  or  3  to  5  grains  of 
carbolic  acid  to  the  ounce  may  be  used. 
A  compound  lotion  of  calamin  and  zinc 
oxide,  like  the  following: — 
IJ   Calaminse,  1  V2  drachms. 
Zinci  oxidi,  1  ^/„  drachms. 
Glyccrinas,  10  minims. 
Acidi  carbolici,  20  grains. 
Aqu£E,  6  ounces. — M. 

is  valuable,  and  may  be  dubbed  on  the 
surface  repeatedly  or  by  means  of  linen 
or  lint  kept  wet  with  it  and  closely  ap- 
plied to  the  diseased  surfaces;  or  a  boric- 
acid  lotion  with  1  or  2  drachms  of  car- 
bolic acid  to  the  pint,  will  be  found  bene- 
ficial, and  especially  applicable  if  the  die- 


ECZEJIA.    TREATMENT. 


647 


eased  surface  is  large;  or  a  boric-acid 
Bolution  (15  grains  to  the  ounce)  may  be 
made  of  the  above  calamin-and-zinc  lo- 
tion. A  so-called  salicylic-acid  paste, 
with  or  without  5  to  10  grains  of  carbolic 
acid  to  the  ounce,  is  often  of  great  ad- 
vantage:— 

IJ   Acidi  salicylici,  10  grains. 

Amyli, 

Zinci  oxidi,  of  each,  2  drachms. 

Petrolati,  4  drachms. 
M.     Make  ointment. 

In  vulvar  eczema  only  emollient  prep- 
arations should  be  employed  —  bran- 
water,  marslimallow  or  chamomile  in- 
fusion; a  little  boric  acid  can  be  added 
to  the  boiled  water  and  serve  as  a  basis 
for  these  lesions.  Following  the  lotion 
a  cataplasm  of  cornstarch  or  potato- 
starch,  made  with  hot  boric  water  and 
applied  cold,  is  indicated.  Little  coin- 
presses  of  tarlatan  soaked  in  borated 
bran-water  recommended,  to  be  placed 
between  the  lesser  lips  of  the  vulva. 
The  dressing  ought  to  be  renewed  after 
each  urination.  During  the  day  borated 
cotton  should  be  applied  to  the  parts. 

As  a  curative  to  be  applied  during  the 
intervals  between  acute  attacks,  the  fol- 
lowing is  suggested: — 

B  Vaselin,  C  V4  drachms. 
O.xide  of  zinc. 

Starch,  of  each,  1  Vi  drachms. 
Salicylic  acid,  1 '/»  drachms. — M. 

The  parts  must  have  been  previously 
bathed  with  borated  bran-water  and 
dried  with  cotton.  Lutaud  (.Tour,  de 
Mod.  de  Paris,  Jan.  12,  '9G). 

A  small  piece  of  buckskin  placed  be- 
tween the  ointment  and  the  other  part 
of  the  dressing  greatly  ameliorates  the 
condition.  Its  good  elTects  are  ascribed 
to  the  ttexibility  of  the  buckskin,  which 
allows  it  to  be  molded  to  every  part  of 
the  surface;  to  the  ease  with  which  it 
can  be  cleansed;  to  the  fact  that  it  does 
not  markedly  absorb  the  ointment  used, 
and  that  therefore  the  part  remains 
moist;  and  to  the  safety  with  which  it 
can  be  removed,  the  newly-formed  epi- 
dermis not  being  torn  away.  Davezac 
(Jour,  de  Mcd.  de  Bordeaux,  No.  51,  '97). 


The  following  recommended  to  allay 
pruritus  in  eczema  of  the  scalp: — 
B  Acidi  salicyl.,  0  grains. 
Menthol,  12  grains. 
01.  lini, 

Aq.  calcis,  of  each,  1  ounce, 
if.     Sig.:     For   external   use.     Stein- 
liardt  (Amer.  Pract.  and  News,  Mar.  15, 
'98). 

Tincture  of  iodine  is  useful  in  eczema 
which   resists   other   methods   of   treat- 
ment.    A    solution    of    cocaine    (5    per 
cent.)    is  first  applied,  after  which  the 
iodine  is  applied  every  evening.    HefTe- 
man  (Semaine  Medicale,  May  13,  19U3). 
An  ointment  of  alumnol,  20  to  40 
grains  to  the  ounce  of  cold  cream,  or 
zinc-oxide    ointment    is    also    valuable. 
One  containing  V2  to  1  drachm  of  bis- 
muth subnitrate  is  also  of  benefit.     A 
compound    calamin    ointment    may    be 
used  in  some   cases  with    great  advan- 
tage:— 

I>  Calamin,  1  drachm. 
Amyli,  '/j  drachm. 
Acidi  salicylici,  10  grains. 
Ung.  zinci  oxidi,  q.  s.  ad  1  ounce. 
— M. 
Diachylon   ointment,   if   a   well-made 
one  is  procurable,  is  often  serviceable. 
The  soothing  salve-mulls  of  zinc  oxide 
and  boric  acid  are  extremely  valuable  in 
some  cases. 

In  some  cases  of  eczema  in  which  the 
grade  of  inflammatory  action  is  subacute, 
stronger  applications  may  be  resorted  to, 
although  even  in  this  class  of  cases  it  is 
advisable  to  begin  the  treatment  with 
the  milder  applications  already  named. 
These  latter  may  finallj%  if  necessary,  be 
made  stronger  and  more  stimulating  by 
the  addition  of  white  precipitate,  red  pre- 
cipitate, calomel,  resorcin,  or  tar.  Of  the 
mercurials,  5  to  30  grains  to  the  ounce 
is  the  usual  proportion  called  for;  of 
resorcin,  5  to  20  grains,  and  of  tar,  '/j  to 
2  drachms  of  the  tar  ointment  to  the 
ounce  of  mild  ointment.  Oil  of  cade 
may  also  be  used  V2  to  2  drachms  to  the 


648 


ECZEMA.    TKEATMEXT. 


ormce  of  ointment.  A  tarrj-  ointment 
such  as  the  following  may  also  prove  use- 
ful in  these  cases: — 

]?  Liquor  carbonis  detergens,  Vs  to 
2  drachms. 
Cerat.  simp.,  q.  s.  ad  1  ounce. 

[Liquor  carbonis  detergens  is  made  by 
mixing  together  9  ounces  of  tincture  of 
soap-bark  and  4  ounces  of  coal-tar,  allow- 
ing it  to  digest  for  eight  days  and  then 
filtering.     Hen'rt  W.  Stelwagon.] 

If  required  to  name  one  remedy  only 
for  eczema,  writer  would  choose  tar;  if 
two,  tar  and  lead;  if  three,  tar,  lead,  and 
mercury.  If  weak  enough,  and  used 
freely  enough,  tar  solutions  will  almost 
invariably  cure  eczema.  Common  tar- 
water  and  solutions  of  carbolic  acid  are 
very  useful;  but  the  solution  of  coal- 
tar  sold  under  the  name  of  liquor  car- 
bonis detergens  is  the  most  convenient 
and  most  certain  remedy.  It  should  be 
used,  however,  in  extreme  dilution.  A 
teaspoonful  to  a  pint  of  water  is  a  com- 
mon strength,  but  often  it  is  prescribed 
much  weaker.  It  should  be  so  weak  that 
it  does  not  smart,  and  it  should  then 
be  employed  like  water.  The  parts 
should  be  bathed  with  it,  and  rags 
soaked  in  it  should  be  laid  over  them, 
and  frequently  wetted  from  outside.  Oil 
silk  should  not  be  used;  at  any  rate, 
not  in  large  pieces.  Jonathan  Hutchin- 
son (Arch,  of  Surg.,  vol.  i,  p.  104,  '99). 

Tar  preparations  are  contra-indicated 
in  children,  milder  applications  should 
be  used.  Ointments  aggravate  acute  ec- 
zemas; a  lotion  of  boric  acid,  menthol, 
and  carbolic  acid  (1  per  cent.)  in  spiritus 
vini  Gallici  is  of  value.  In  moist  eczema 
with  crusts,  after  removal  of  the  latter, 
compresses  of  silver  nitrate  (1  in  400)  are 
applied  twice  daily  for  two  hours,  and 
in  the  intervals  diachylon  ointment. 
Cases  of  universal  eczema  are  treated  in 
bed,  vagelin  being  applied  several  times 
a  day,  and  the  inside  of  the  night-dress 
dusted  with  starch.  Rille  (Wiener  klin. 
Rund.,  Mar.  18  and  25,  1900). 

lodol-ariBtol,  5  to  20  or  more  grains  to 
the  ounce  of  ointment-base,  may  also  be 
commended.      In    some    instances    pre- 


liminary paintings  for  several  days  with 
a  saturated  sohition  of  picric  acid  has 
proved  of  advantage,  waiting  for  the 
films  or  scale  thus  formed  to  come  up, 
and  then  applying  a  mild  ointment  for 
a  few  days,  and  then  res\iming  the  picric- 
acid  painting. 

Picric  acid  is  indicated  in  those  forms 
of  eczema  in  which  the  inflammation  is 
acute  and  superficial,  and  where  the  le- 
sions are  mostly  epidermic.  The  kera- 
toplastic  action  of  the  remedy  cannot 
display  itself  in  the  chronic  forms  ac- 
companied by  induration  of  the  skin 
and  particularly  by  epidermic  thicken- 
ing; picric  acid  is  incapable  of  modifying 
these  chronic  lichenoid  eczemas.  On  the 
other  hand,  the  keratogenic  properties 
of  the  agent  find  an  excellent  field  of 
action  in  acute  eczemas  with  swelling 
of  the  integument,  superficial  ulceration, 
and  weeping.  Under  its  influence  the 
inflammation  rapidly  subsides,  and  the 
acid  forms  (on  contact  with  the  ulcer- 
ated and  oozing  surfaces)  a  protective 
layer  composed  of  coagulated  proteid 
substances  and  of  epithelial  dC'brls,  un- 
der which  healing  takes  place  rapidly. 
Picric  acid  has  the  further  advantage 
that  it  immediately  stops  itching;  this 
elTect  is  produced  in  chronic  as  well  as 
acute  forms  of  the  disease.  In  acute 
eczema  a  cure  is  effected  in  from  ten  to 
fifteen  days.  Aubert  (ThOse  de  Paris, 
No.  34,  '97). 

In    some    instances    applications    of 
dressings  of  a  more  or  less  fixed  character 
are  of  advantage,  such  as  the  gelatin 
dressing,  tragacanth  dressing,  and  aca- 
cia dressing. 
GELATfN  Dressing: — 
IJ  Gelatin,  15  to  25  parts. 
Zinc  oxide,  10  to  15  parts. 
Glycerin,  15  to  35  parts. 
Water,  50  parts. 

To  this  may  be  added  2  parts  of  ich- 
thyol. 

This  is  heated  over  a  water-bath  each 
time  it  is  to  be  employed,  a  good  coating 
painted   on   with   a   brush,   and   when 


ECZEMA.    TREATMENT. 


649 


partly  dry — in  one  to  five  minutes — the 
parts  wrapped  with  a  gauze  bandage. 
The  whole  dressing  becomes  dry  and 
fixed,  and  may  remain  on  from  two  to 
six  days,  and  then  soaked  off,  cleansed, 
and  a  new  dressing  reapplied.  In  some 
cases  the  larger  quantity  of  gelatin  and 
smaller  quantity  of  glycerin  may  prefer- 
ably be  incorporated,  and  then  the  gela- 
tin coating  will  dry  more  quickly  and 
will  form  a  suificient  dressing  without 
the  gauze  bandage,  although  this  latter 
seems  to  be  of  real  advantage  in  keeping 
the  gelatin  from  becoming  soiled  and 
from  being  rubbed  off.  If  the  gauze  is 
not  used  a  small  quantity  of  a  dusting- 
powder  may  be  applied  over  the  gelatin. 

The  above  is  especially  applicable  in 
the  treatment  of  eczema  of  the  lower 
legs.  Other  drugs  may  be  added,  but  cer- 
tain medicaments  exercise  an  inhibitory 
influence  on  the  setting  of  the  gelatin, 
and  if  used  should  always  be  used  with 
a  dressing  more  rich  in  gelatin  and  with 
less  glycerin  and  less  water;  such  reme- 
dies are  resorcin,  salicylic  acid,  and  car- 
bolic acid.  '\^nntc  precipitate,  sulphur, 
and  acetanilid  may  also  be  incorporated 
in  such  dressings. 

TH.\GACAXTn  Dressing. — Pick's  trag- 
acanth  dressing — linimentum  exsiccans 
— is  also  a  useful  fixed  dressing  in  the 
cooler  weather.    It  consists  of 

IJ  Tragacanth,  5  parts. 
Glycerin,  2  parts. 
Boiling  water,  95  parts. 

To  this  can  be  added  2  per  cent,  of 
boric  acid  or  2  per  cent,  of  carbolic  acid, 
and  5  to  10  per  cent,  of  zinc  oxide  or  cala- 
min,  or  equal  parts  of  both. 

This  is  smeared  in  a  thin  coating  over 
the  diseased  area  and  allowed  to  dry  on, 
which  usually  requires  several  minutes. 
The  parts  can  then  be  bandaged  or  be 
sprinkled  with  some  indifferent  dusting- 


powder.  It  is  a  more  simple  dressing 
than  the  gelatin  application,  requires  no 
preparation,  but  is,  upon  the  whole,  less 
useful.  Other  medicaments  may  be 
added  in  addition  to  those  already 
named. 

Acacia  Dressing. — This  constitutes 
another  fixed  dressing  that  is  readily  ap- 
plied and  which  may  be  used  on  dry 
parts.  A  good  formula  is  the  follow- 
ing:— 

1^  Mucilage  of  acacia,  5  or  6  parts. 
Glycerin,  1  part. 

Zinc  oxide  or  calamin,  or  a  mixt- 
ure of  both,  2  parts. 

Carbolic  acid  or  any  other  drug  may 
also  be  added  if  desired. 

This  is  painted  on  with  a  brush  or 
smeared  over  in  a  thin  layer  with  the 
finger;  it  dries  in  a  few  minutes.  If  at 
all  sticky  or  for  further  prevention 
against  this,  a  dr)'  powder  of  zinc  oxide 
or  talcum  can  be  applied  over  it. 

Another  method  of  treating  these 
cases  w'hich  can  at  times  be  employed 
with  great  benefit  is  by  means  of  the  so- 
called  salve-  and  plaster-  mulls  (made  by 
Beiersdorf).  These  are  variously  medi- 
cated. The  mild  salve-mulls  and  the 
moderately  strong  salve-mulls,  and  the 
moderate  strength  plaster-mulls  are 
adapted  for  the  subacute  cases.  While 
especially  useful  in  some  cases,  occa- 
sionally their  action  is  not  so  satisfactory. 
Their  disadvantage  is  their  costliness. 

In  eczema  of  a  chronic  sluggish  type 
strong  applications  must  be  usually 
made  before  a  result  is  brought  about. 
The  different  remedies  and  combinations 
referred  to  in  speaking  of  the  treatment 
of  the  subacute  type  may  be  first  tried; 
later,  when  necessary,  treatment  may  as- 
sume a  bolder  character,  various  reme- 
dies being  used  in  stronger  proportion. 
Of  value  in  many  of  these  cases  may  be 


650 


ECZEilA.    TREATMENT. 


mentioned — ointments  of  calomel,  40  to 
SO  grains  to  the  ounce;  white  precipi- 
tate of  about  the  same  strength;  salicylic- 
acid  ointment,  20  to  60  grains  to  the 
ounce;  resorcin,  about  the  same  propor- 
tion; sulphur,  10  to  60  grains  to  the 
oiince  (used  at  first  with  caution);  tar 
ointment,  either  in  official  strength  or 
somewhat  weakened;  or  the  liquor  car- 
bonis  detergens,  with  simple  cerate  or  as 
a  wash,  pure  or  diluted. 

Zinc-oxide  paste  containing  1  to  2  per 
cent,    of    yellow    oxide    of    mercury    is 
recommended    in    the   squamous   or   the 
milder   grades   of   papular    or   vesicular 
eczema     of     children.       L.     Leistikow 
(Monats.  f.  prakt.  Derm.,  Sept.  1,  1900). 
Silver  nitrate  applied  in  the  form  of 
a    1-per-cent.   solution   favorably   aiJects 
eczema   in  all   its  forms.     J.   C.   Dunn 
(Med.  News,  Sept.  29,  1900). 
An  ointment  of  20  to  40  grains  of 
pyrogallic   acid   to   the   ounce   may  be 
cautiously  tried  in  obstinate  cases.    The 
same  may  be  said  with  regard  to  chrysa- 
robin;  but  this  latter  should  not  be  used 
about  the  face.    The  various  fixed  dress- 
ings referred  to  in  the  treatment  of  the 
subacute  variety  will  also  be  of  value  in 
the  chronic  tjrpe.    Collodion  may  also  be 
used  as  a  basis  for  fixed  dressing  in  local- 
ized areas  of  disease.    The  stronger  salve- 
and  plaster-  mulls  and  the  medicated 
rubber  plasters,  the  latter  especially  in 
the  sclerous  and  verrucous  forms,  are 
also  of  distinct  advantage  in  these  cases; 
in    sluggish,    thickened   areas    repeated 
shampooing  with   green   soap   and  hot 
water,  rinsing  off,  and  immediately  fol- 
lowed by  a  mild  ointment  applied  as  a 
plaster  acts  admirably  in  some  instances. 
Painting  such  areas  with  solutions  of 
caustic  potash,  1-  to  5-per-cent.  strength, 
allowing  to  act  for  a  few  minutes,  then 
rinsing  off  and  applying  a  mild  ointment 
is  a  somewhat  similar  method  of  treat- 
ment which  is  serviceable  at  times.     In 
some  obstinate  cases  thoroughly  stirring 


the  skin  with  a  strong  remedy,  insti- 
tuting a  substitutive  inflammation,  and 
then  applying  mild  remedies  will  not  in- 
frequently bring  about  the  desired  result. 
Superficial  scarification  of  patches  of 
eczema  employed  in  certain  selected 
cases.  The  patches  are  scarified  in  par- 
allel lines,  one  to  one  and  a  half  milli- 
metres apart,  in  one  direction  only,  by 
a  very  pointed  instrument  penetrating 
to  the  superficial  layer  of  the  dermis. 
These  areas  are  then  encouraged  to  bleed 
and  bathed  with  boiled  water,  and  then 
covered  with  tarlatan  dipped  in  boiled 
water.  On  reaching  home  cold  potato- 
starch  poultices  are  applied  until  the 
next  treatment — generally  three  or  four 
days  later.  Before  beginning  the  treat- 
ment the  patches  are  prepared  by  the  ap- 
plication of  continuous  cold  plain  starch 
poultices.  Six  to  si.xteen  treatments 
suffice  for  a  cure.  A  reaction  is  set  up 
in  the  patches,  but  no  scars  result.  This 
treatment  is  to  be  used  only  in  special 
cases  characterized  by  isolated  disks  in 
limited  number.  Jacquet  (Bull.  G6n.  de 
Therap.,  Jan.,  '98). 

In  infants  the  face  or  face  and  scalp 
are  by  far  its  common  site.  The  disease 
may,  however,  occur  upon  any  part  at 
any  age.  The  treatment  in  regional  ec- 
zema is  essentially  the  same  as  the  treat- 
ment of  eczema  of  any  part,  common 
sense  suggesting  selection  or  avoidance 
which  the  character  of  the  region  may 
suggest;  as,  for  instance,  upon  hairy 
parts,  as  the  scalp.  Ointments  containing 
large  percentages  of  pulverulent  sub- 
stances, such  as  the  so-called  salicylic- 
acid  paste,  should  not  be  employed,  as 
they  would  tend  to  produce  crusting, 
matting,  and  messiness. 

In  treating  a  case  of  infantile  eczema 
the  search  for  the  cause  should  go  hand 
in  hand  with  the  treatment,  which  is 
otherwiHc  only  palliative;  carefully  ex- 
amine both  child  ond  motlier.  In  an 
acute  eczema  of  a  few  days'  standing 
decided  ameliqration  may  be  obtained  by 
calomel.  Some  cases  are  benefited  by 
judicious   use   of   codlivcr-oil    and   iron. 


ECZEMA. 


ELATEKIUM  AND  KLAIERIX. 


651 


The  local  treatment  is  very  important 
for  the  comfort  of  the  patient.  The 
crusts  can  be  removed  by  salicylated  oil. 
Washing  with  water  should  be  strictly 
interdicted,  oil  being  used  as  a  substi- 
tute. The  local  conditions  can  now  be 
treated  very  happily  by  Lassar's  paste: — 

R  Zinc,  oxid., 

Pulv.  aniyli,  of  each,  2  drachms. 
Petrolatum,  V2  ounce. 

In  acute  cases,  boric  acid,  10  to  20 
grains  to  the  ounce,  or  in  less  acute  cases 
salicylic  acid,  10  grains  to  the  ounce, 
may  be  added.  Ichthyol,  5-  to  10-per- 
cent, should  be  added  in  the  older  cases, 
where  the  skin  is  thickened  and  scaling 
is  excessive.  In  all  cases  the  applica- 
tion should  be  changed  two  or  three 
times  daily,  every  precaution  being  taken 
to  see  that  the  skin  is  kept  covered 
and  scratching  prevented.  Alger  (Araer. 
Med.-Surg.  Bull.,  Aug.  1,  '90). 

Favorable  results  obtained  in  the 
treatment  of  eczema  by  red  solar  light. 
The  eruptive  regions,  previously  covered 
with  thin  silk  stuff  of  an  intense-red 
color,  were  exposed  directly  to  the  solar 
light  as  long  as  possible  (four  hours  in 
one  case).  In  all  the  patients  thus 
treated  there  was  a  rapid  disappearance 
of  the  symptoms.  W.  "Winternitz  (Sem. 
M«d.,  Aug.  15,  1900). 

There  are  two  special  forms  of  eczema 
which  occur  at  the  change  of  life — and 
the  commonest,  that  which  comes  most 
before  practitioners,  is  acute  eczema  of 
the  head  and  face.  There  is  usually 
considerable  flushing,  sweating,  and 
other  nervous  phenomena,  headaches, 
and  disturbances  of  the  digestive  tract 
— dyspepsia  and  constipation.  A  spare 
woman  at  that  time  of  life  suddenly  be- 
gins to  flush  in  the  face,  perhaps  after 
taking  a  meal;  later  the  disorder  be- 
comes a  little  more  acute;  she  gets  an 
acute  eczema  of  the  scalp,  and  it  spreads 
down  all  over  her  face.  For  that  condi- 
tion there  is  no  drug  or  combination  of 
drugs  which  is  of  such  service  to  re- 
lieve the  symptoms,  not  only  the  eczema, 
but  all  the  symptoms  mentioned,  as 
ichthyol.  It  can  be  given  in  tabloids 
covered  with  keratin,  which  does  not 
dissolve  until  it  gets  into  the  intestine. 


The  dose  should  be  2  'A  grains,  to  begin 
with,  after  each  meal.  At  the  end  of 
two  or  three  days  it  should  be  increased 
to  5  grains,  then  to  7  Vj  grains,  and  then 
to  10  grains.  If  the  patient  tastes  it 
much,  the  dose  should  be  reduced  a 
little. 

With  regard  to  local  treatment,  this 
form  of  eczema  requires  rather  more 
active  treatment  than  is  needed  at  any 
other  time.  Such  cases  usually  bear 
fairly  strong  applications  of  sulphur  and 
resorcin. 

The  other  form  at  change  of  life  is 
the  very  acute  eczema  which  occurs 
about  the  vulva  and  anus.  Malcolm 
Morris  (Lancet,  May  4,  1901). 

Hexry  W.  Stelwagon, 

Philadelphia. 

ELATERIUM    AND    ELATERIN. — 

Elaterium  is  a  sediment  deposited  from 
the  juice  of  the  squirting  cucumber 
{Ecballium  elaterium,  A.  Rich).  This 
sediment,  when  dried,  appears  in  fri- 
able cakes  about  Vio  of  an  inch  in  thick- 
ness, flat  or  slightly  curled,  and  of  a 
pale-green,  graj'ish-green,  or  grayish- 
yellow  color,  the  yellow  tinge  appearing 
when  the  drug  is  old.  Its  odor  is  feeble 
and  its  taste  bitter  and  slightly  acrid.  It 
is  partly  soluble  in  hot  water.  It  is  offi- 
cial in  the  B.  P.,  but  not  in  the  U.  S.  P. 
Elaterin  (elaterinum— r.  S.  P.,  B.  P.) 
is  the  active  principle  of  elaterium,  be- 
ing found  therein  in  amounts  varying 
from  5  to  40  per  cent.  It  is  a  neutral 
principle  and  appears  as  small,  white,  or 
yellowish-white  crj'stals,  without  odor. 
but  of  a  very  bitter  and  acrid  taste.  It 
is  freely  soluble  in  chloroform,  slightly 
soluble  in  ether  and  alcohol,  and  in- 
soluble in  water.  Elaterin  is  preferred 
for  administration  because  of  the  great 
variability  in  strength  of  different  speci- 
mens of  elaterium. 

Dose  and  Physiological  Action. — The 
dose  of  elaterium  is  '/,  to  Vi  grain. 
Elaterin  is  given  in  doses  of  Vao  to  'A, 
grain,  preferably  in  granules;  a  tritura- 


652 


ELATERILM  AXD  ELATERIN. 


ELEPHANTIASIS. 


tion  of  elaterin  (10  per  cent.)  is  official, 
the  dose  being  '/„  to  1  grain. 

Elaterium  is  a  decided  irritant  to  the 
mucous  membranes  and  also  to  the  skin. 
When  given  internally  its  chief  action, 
in  man,  is  to  produce  profuse  watery 
stools.  When  given  in  proper  doses, 
these  large  water  evacuations  occur  with- 
out undue  pain  or  any  apparent  gastro- 
intestinal irritation,  and  for  these 
reasons  elaterium  claims  first  rank  as  an 
hydragogue  purge. 

Poisoning  by  Elaterium. — In  large 
doses  or  in  debilitated  persons  its  use 
may  produce  so  much  prostration  and  ex- 
haustion as  to  demand  the  exhibition  of 
stimulants  and  other  supporting  meas- 
ures. In  addition  to  nausea,  vomiting, 
excessive  purging,  and  exhaustion,  the 
use  of  too  large  doses  of  this  drug  may 
even  be  followed  by  death  from  gastro- 
enteritis. Debility  from  old  age  or  other 
cause  and  gastro-intestinal  irritation  or 
inflammation  contra-indieate  its  use. 
The  subcutaneous  use  of  elaterium,  al- 
though capable  of  producing  catharsis,  is 
not  advised,  on  account  of  the  severe 
local  irritation  and  inflammation  thereby 
induced. 

Treatment  of  Elaterium  Poisoning. — 
The  treatment  of  poisoning  by  this  drug 
is  practically  that  of  gastro-enteritis. 
Morphine  should  be  given  liypodermic- 
ally,  and  hot  applications  (stupes  or  flax- 
seed poultices)  should  be  made  over  the 
abdomen  to  allay  the  pain  and  control 
the  irritation  and  diarrhoea.  Especial 
care  should  be  had  in  the  selection  of  a 
proper  diet.  Bland,  easily  digested,  and 
unirritating  articles  of  food  should  be 
selected.  Predigcsted  foods  arc  espe- 
cially useful  in  these  cases. 

Therapeutics. — In  general,  elaterium 
is  indicated  in  conditions  demanding 
fluid  depletion;  the  use  should  not  be 
continued  if  the  stomach  becomes  dis- 


ordered or  the  appetite  impaired.  It 
ought  never  be  used  in  cases  of  debility 
or  marked  exhaustion,  and  may  be  fol- 
lowed with  advantage  by  alcoholic  stimu- 
lants soon  after  its  action  is  manifest. 
Its  use  is  suggested  in  cerebral  conges- 
tion on  account  of  its  depletant  and  re- 
constant  eft'ects.  In  poisoning  by  nar- 
cotics and  in  acute  alcoholism  elaterium 
is  indicated  when  the  emunctories  are 
not  acting  freely. 

Ascites  and  Dropsical  Effusions. 
— In  these  affections  elaterium  is  a  drug 
of  great  value,  though  one  whose  use  de- 
mands much  care  and  judgment.  In 
dropsy  depending  on  aortic,  obstructive, 
or  regurgitant  disease  it  is  especially  use- 
ful, given  in  small  doses  at  first,  about 
Vo  grain,  on  alternate  mornings  at  say 
5  o'clock,  so  that  its  action  is  finished 
by  noon.  This  is  claimed,  by  Hyde 
Salter,  to  quiet  the  heart,  relieve  the 
dyspnoea,  lessen  the  pulmonary  conges- 
tion, and  diminish  the  hydrothorax. 

UEiEMiA. — Urasmic  poisoning  is  much 
benefited  through  the  use  of  elaterium, 
as  it  aids  the  elimination  of  the  urtemic 
poison  by  the  bowel.  It  is  especially  in- 
dicated when  ura2mia  is  associated  with 
dropsical  effusion. 

Liquid  Effusions  of  Inflammatory 
Origin. — Under  this  head  belong  pul- 
monary oedema,  pleurisy,  and  pericardi- 
tis, in  all  of  which  the  hydragogue 
catharsis  induced  by  elaterium  may  be 
beneficial. 

ELEPHANTIASIS —Gr.,  E?.E<^>ag,  an 
elephant. 

Definition  — Elephantiasis  is  a  chronic 
endemic  and  sporadic  hyperplasia  of  the 
skin  and  subcutaneous  tissues,  following 
an  inflammatory  embolus  of  the  lymph- 
and  blood-  channels,  and  resulting  in  an 
inordinate  enlargement. 

Symptoms.  —  The   legs  are  involved 


ELEPHANTIASIS.    SYMPTOMS. 


653 


most  frequently;  the  genitalia  of  both 
sexes  follow  closely,  while  many  other 
parts — the  face,  body,  and  extremities 
— are  occasionally  attacked. 

Case  of  congenital  elephantiasis.  Men- 
tal development  considerably  below  par. 
Had  congenital  hypertrophy  of  the  face, 
eyelid,  and  scalp,  confined  to  right  side. 
The  right  eye  had  become  diseased  in 


Congenital  elephantiasis  of  the  face  and 
scalp.     {Coley.) 

early  childhood,  and  had  been  removed. 
The  hypertrophy  seemed  confined  chiefly 
to  the  skin  and  subcutaneous  tissue;  the 
upper  eyelid  was  greatly  thickened  and 
pendulous,  reaching  down  to  the  upper 
of  the  alfE  nasi.  There  was  a  well- 
marked,  irregular  depression  in  the  re- 
gion of  the  squamous  portion  of  right 
temporal  bone,  and  in  one  place  a  slight 
loss  of  bony  substance.  Over  the  poste- 
rior portion  of  the  right  parietal  bone 
was  a  soft,  flabby  tumor  of  the  scalp 
about  the  size  of  a  small  hen's  egg, 
freely  movable,  and  covered  with  a  nor- 
nuil  growth  of  hair.  Coley  (N.  Y.  Med. 
Jour.,  June  20,  '91). 

Three  cases  of  elephantiasis  of  the 
upper  lid,  in  one  of  which  both  eyes 
were  afTected.  Goraud  (Annales  de  la 
Polyclin.  de  Bordeaux,  Apr.,  '92). 


The  right  leg  is  more  often  attacked 
than  the  left,  occasionally  both  are  in- 
volved; the  scrotum  is  affected  with 
greater  frequency  than  the  penis  in  the 
male,  and  the  labia  majora  and  minora 
than  the  clitoris  in  the  female. 

Elephantiasis  of  the  vulva  observed  in 
a  mulatto  woman  who  was  four  months 
pregnant.  The  tumor  encroached  upon 
the  vaginal  orifice  so  much  {the  clitoris 
and  labia  majora  and  minora  being  all 
involved)  that  delivery  at  term  would 
have  been  impossible.  Hence  the  mass 
was  removed  with  the  knife,  being  first 
constricted  with  an  elastic  ligature  tied 
under  three  long  pins  passed  beneath  the 
tumor.     Bleeding  vessels  were   thus  se- 


m 


■*v 


',r) 


Case  of  elephantiasis  of  the  scrotum. 
{I'thcinann.) 

o\ired  separately  and  the  wound  closed 
by  sutures.  Pregnancy  was  not  dis- 
turbed. Mundfi  (Araer.  Jour,  of  Obstet., 
Oct.,  '95). 

Case  of  a  man,  19  years  old,  in  whom 
the  foreskin  and  scrotum  began  to  en- 


654 


ELEPHANTIASIS.    SYMPTOMS. 


large  at  the  age  of  4,  continuing  until 
it  had  reached  the  enormous  size  shown 
in  illustration.  Operation  successfully 
performed.  L'themanu  (Deutsche  med. 
Woch.,  Dec.  5,  '95). 

Form   of  chronic   enlargement   of   the 
testes  frequently  met  with  in  the  inhab- 
itants of  warm  countries,  and  associated, 
in  many  instances,  with  elephantiasis  of 
the  scrotum  and  lower  extremities.    This 
form  of  testicular  enlargement,  which  is 
associated  with  swelling  and  induration 
of   the   epididymis  and   spermatic   cord, 
even  when  existing  alone,  is  held  to  be 
invariably  of  the  nature  of  elephantiasis, 
and  not  due  to  any  malarial  influence. 
After  castration   and  during  an   opera- 
tion  for   hydrocele,   it   has    been   found 
that  this  condition  is  the  result  of  a  dis- 
tension of  the  lymph-vessels  of  the  tunica 
albuginea,  epididymis,  and  cord,  and  of 
an   excessive    proliferation   of   the   con- 
nective tissue.     The  filaria  undoubtedly 
plays  a  considerable  part  in  the  genesis 
of   such   morbid   conditions.     Le   Dentu 
(Revue  de  Chir.,  Jan.,  '98). 
Xo  inconTenience  or  pain  accompanies 
the  disease  in  the  majority  of  cases,  but 
very  often  when  the  scrotum  is  the  part 
attacked  stomachic  and  nervous  distress 
is  encountered.    Eadiating  pains  may  be 
observed   in   the   seminal   nerves,   thus 
causing   intense   nausea   and   vomiting. 
Hydrocele  may  be  induced. 

The  prodromic  stages  differ  according 
to  whether  the  elephantiasis  occurs  in 
hot  or  cold  climates.  In  hot  countries 
there  appears  a  preliminary  fever  termed 
"elephantoid  fever,"  which  is  preceded 
by  pains  of  great  intensity  in  the  lumbar 
region,  accompanied  with  retching  and 
vomiting,  cold  shiverings  located  along 
the  spine,  followed  by  fever  and  profuse 
perspiration  in  successive  alternations. 
The  colder  atmospheres  do  not  occasion 
such  marked  distress  during  this  early 
stage. 

In  patients  BufTering  from  elephantia- 
sis once  or  twice  a  month  there  is  an 
excess  of  fever.  The  local  symptoms  ac- 
companying the  fever  are  those  of  lym- 
phan!,'itis  with  ganglionic  enlargemcnta. 


These  attacks  of  lymphangitis  with  fever 
coincide  with  the  invasion  of  the  con- 
nective tissue  of  the  hypoderm  and  of 
the  associated  lymph-channels  by  mi- 
crobes. The  visible  lesions  are  the  result 
of  hundreds  of  febrile  crises,  each  ac- 
companied by  a  fresh  advance  of  cedema. 
Each  new  oedematous  deposit  is  prob- 
ably followed  by  local  organization  of 
the  emigrated  embryonal  cells  in  adult 
connective  tissue.  Tropical  elephantia- 
sis is  usually  due  to  the  Filaria  sail- 
puinis  hoininis.  Sabouraud  (Annales  de 
Derm,  et  de  Syphil.,  May,  '92). 

The  course  of  the  affection,  whether 
occupying  the  leg  or  elsewhere,  is  char- 
acterized by  frequent  exacerbations. 
Deeply-seated,  recurrent  forms  of  derma- 
titis, or  attacks  of  an  erysipeliform  (or 
true  erysipelas,  the  streptococcus  of 
erysipelas  being  found  in  some  cases)  in- 
flammation, with,  at  times,  involvement 
of  the  lymphatics  (from  which  milky  or 
chylous  discharges  may  be  noted  with 
or  without  puncture)  are  encountered. 
While  these  phenomena  are  primarily 
localized  in  the  deeper  tissues,  the  skin 
does  not  seem  to  be  attacked  until  later, 
when  it  presents  nodular  increase  in  size. 

With  proper  measures  these  symptoms 
abate,  only  to  reappear  at  some  later 
period.  At  each  successive  attack  the 
part  is  noted  to  have  increased  in  size 
to  an  appreciable  extent.  These  recur- 
rences of  fever  and  oedema  may  appear  at 
intervals  of  weeks  only,  while  months  or 
years  may  intervene  between  each  recru- 
descence. At  times  the  recurrences  of 
these  phenomena  may  be  so  frequent  or 
so  close  that  the  previous  inflammation 
has  not  had  time  to  disappear.  As  each 
attack  leaves  an  increase  in  size  we  may, 
after  a  time,  find  a  gigantic  enlargement 
of  the  part  involved.  These  inflamma- 
tory phenomena  may  not  always  be  ob- 
served, as  the  part  may  often  be  found 
to  increase  in  size  without  their  apparent 
assistance.  It  is  diflicult  to  cause  pitting 
in  these  structures,  owing  to  the  general 


ELEPHANTIASIS.    DIAGNOSIS. 


Goo 


hyperplasia.  The  skin,  as  previously 
noted,  does  not  appear  to  participate  in 
this  process  early,  but  later  it  becomes 
likewise  affected.  It  is  tightly  stretched, 
glossy  or  waxy,  with  pigmentary  changes 
of  color  varying  from  brownish  red  or 
pinldsh  red  to  one  of  dusky  brown. 
Upon  its  surface  may  be  seen  an  accumu- 
lation of  sebaceous  material,  with  here 
and  there  desquamations  of  epithelium. 
The  linear  fissures  of  the  skin  may  in- 
crease so  greatly  that  enormous  sulci  may 
be  formed.  Hard  or  soft  tubercles  may 
appear  upon  its  surface  at  various  parts, 
either  showing  some  scaly  desquamation 
at  their  summit  or  becoming  denuded  of 
epithelium;  they  present  numerous 
bleeding-points  or  the  top  of  the  tuber- 
cles may  be  one  bleeding  surface.  In 
fact,  many  cases  seem  to  present  a 
chronic  eczema  upon  the  skin  of  the 
thickened  part,  and  this  appears  to  fol- 
low its  usual  characters.  In  other  cases 
shallow  ulcers,  which  resemble  ordinary 
breaks  of  continuity,  may  be  found  at 
points  over  the  affected  skin.  The  parts 
around  the  joints  form  decided  strictures, 
and  the  overlapping  enlargement  thus 
causes  deep  fissures  in  which  a  milky  or 
chylous  exudation,  intermixed  with  se- 
baceous discharge,  cause  painful  m.acera- 
tion  of  the  inclosed  skin.  At  certain 
points  the  lymphorrhagia  may  be  so  ex- 
cessive as  to  cause  great  depression  of 
vitality. 

While  this  increase  occurs  in  the  softer 
parts  of  the  affected  structures,  the  bones 
alike  share  the  enlargement  in  all  their 
dimensions,  and  glandular  involvement 
is  often  noted.  The  leg  resembles  closely 
its  counterpart  in  the  elephant  both  ex- 
ternally and  in  size-proportion.  The 
■weight  becomes  out  of  all  proportion  to 
other  parts  of  the  body,  and  while  sub- 
jective sensations  are,  for  the  most  part, 
encountered    during    the    inflammatory 


attacks,  they  may  be  observed  after  the 
affected  portion  has  been  allowed  to  re- 
main in  one  position  for  an  indefinite 
period.    Pain  is  then  found  to  follow  ex- 
cessive  fatigue,    and   tearing,    stabbing 
sensations  are  reverberated  throughout 
the  affected  leg.     When  other  parts — 
such  as  the  scrotum  and  penis  or  the 
labia  and  clitoris — are  involved,  the  same 
process  intervenes  and  the  enlargement 
hangs  down  between  the  legs,  and  may 
weigh  many  pounds.    The  penis  usually 
becomes  indistinguishable  in  the  large 
mass  and  an  opening  or  groove  is  left 
through  which  the  urine  trickles.    The 
face  (cheeks  and  nose),  shoulders,  arms, 
forearms,  and  the  hands  may  share  in 
the  tumefaction,  but  do  not  show  the 
same  complications  observed  when  the 
leg  or  genitals  are  involved.     Other  en- 
largements of  enormous  extent  are  de- 
scribed, such  as  the  elephantiasis  telangi- 
ectodes of  Virchow,  which  is  of  congen- 
ital origin  and  affects  the  vascular  tissues. 
Elephantiasis   lyniphangicctatica    coii- 
frenita  is  a  very  rare  congenital  anom- 
aly  of  the  skin.     In   the   majority   of 
pases    the    infants   afTccted    by    it   have 
been  still-born,  or  have  died  soon  after 
birth.      In    only    a    few    instances   have 
they  survived  and  come  under  clinical 
observation:     and    in    such    cases    the 
area  of  skin  implicated  by  the  disease 
has  been  small.     In  a  case  obscn-ed  by 
the  writer,  a  microscopical  examination 
revealed   a   marked   hypertrophy   of  the 
white  fibrous  tissue  of  the  corinm  and 
subcutaneous  tissue,  with  a  new  forma- 
tion of  fibrous  elements  like  a  fibroma. 
This  fibrous  stroma  was  broken  up  by 
dilated  lymphatic  spaces  and  channels, 
containing   leucocytes   and   plasma-cells. 
Many  of  the  deeper  cells  of  the  Mal- 
pighian  layer  were  pigmented,  and  pig- 
ment granules  were  present  in  a  number 
of  the  connective-tissue  spindles  in  the 
upper  part   of  the  corium.     E.  VoUnier 
(.\rchiv  f.  Dcrmat.  u  Syph..  .Tune.  1003). 
Diagnosis.  —  Cases    of    elephantiasis 
after  reaching  their  full  development  are 


656 


ELEPHANTIASIS.    ETIOLOGY. 


easily  recognizable.  The  enlargement, 
with  difficulty  to  cause  pitting;  the  ap- 
pearance of  warty  or  keloid-like  tumors; 
the  history  of  repeated  attacks  of  ery- 
sipelas, deep  dermatitis,  or  a  recurrent 
eczema,  should  be  sufficient  to  draw  at- 
tention to  this  affection. 

Care  shovdd  be  taken  not  to  confound 
elephantiasis  with  pendulent  tumors, 
such  as  overhanging  forms  of  fibroma, 
which  may  closely  resemble  the  enlarge- 
ment found  in  the  former  affection.  En- 
largements due  to  eczema  or  syphilis  will 
usually  present  symptoms  of  both  of 
these  conditions  sufficient  to  prevent 
error  if  care  be  taken.  Acromegaly  and 
myxcedema  present  symptoms  which  will 
be  sufficient,  if  carefully  studied,  to  make 
a  proper  diagnosis  of  these  conditions. 
Constriction  of  a  limb  by  means  of  band- 
ages happens  very  frequently,  and,  as  en- 
largement may  follow,  close  examination 
will  reveal  the  reason  for  this  increase. 
In  fact,  close  attention  to  every  detail 
should  be  carefully  studied,  when  the 
diagnostic  differences  of  the  several  simi- 
lar affections  may  easily  be  detected. 

Etiology. — While  the  affection  may  be 
observed  in  any  country,  certain  regions, 
owing  to  their  climate,  are  noted  for  the 
prevalence  of  an  endemic  type  of  ele- 
phantiasis, while  sporadic  types  prevail 
in  other  countries.  It  attacks  both  sexes, 
although  the  male,  however,  three  times 
more  frequently  than  the  female.  Age 
does  not  seem  to  influence  its  appearance, 
but  middle  or  adult  life  shows  the  largest 
number  of  cases.  Congenital  types  may 
be  noted. 

The  influence  of  heredity  has  been 
shown  by  many  recorded  cases.  Change 
of  climate  seems  to  lessen  the  tendency 
of  the  disease,  and  cases  are  benefited  in 
which  the  affection  has  proceeded  for 
some  time.  Unhygienic  surroundings — 
such  as  malarious  districts  or  parts  bor- 


dering upon  the  sea — exert  a  deleterious 
influence.  The  fair  types  of  mankind  do 
not  show  as  marked  a  tendency  to  the 
affection  as  do  the  darker  types. 

The  mosquito  is  thought  to  play  an 
important  part  in  the  production  of 
elephantiasis.  Encroachments  of  large 
tiunors,  as  well  as  pressure  of  various 
kinds,  upon  the  veins  and  lymphatics  are 
also  considered  as  predominating  eti- 
ological factors. 

Case  in  which,  two  j'eais  before,  the 
patient  had  acquired  syphilis  and  suf- 
fered from  suppurative  buboes  in  both 
groins,  the  left  side  being  the  worse; 
she  treated  the  afl'ection  herself.  A 
year  later  she  first  noticed  an  increase 
in  the  labium  majus  of  the  left  side,  and 
this  has  steadily  gone  on  until  it  is  the 
size  of  the  list.  In  both  groins  there  are 
scars,  that  on  the  left  being  deeper  and 
more  extensive.  This  case  regarded  as 
having  an  important  bearing  on  the 
treatment  of  bubo.  The  extensive  de- 
struction of  the  inguinal  lymphatic  ves- 
sels was  the  result  of  neglect  of  early 
incision  and  antiseptic  treatment  of  the 
suppurative  buboes.  The  elepliantiasis 
described  is  due  to  the  obliteration  of 
the  lymphatics.  INI.  Schreider  (Denn. 
Zeit.,  B.  2,  H.  5,  '95). 

Case  of  elephantiasis  observed  in  a 
little  girl  3  years  old.  Her  grandmother 
had  had  several  attacks  of  lymphangitis 
of  the  legs,  followed  by  elephantiasis. 
The  mother  of  the  child  never  had  either 
of  these  diseases  or  erysipelas.  A  fall 
upon  the  abdomen  is  thought  to  have 
an  etiological  relationship  to  the  disease 
of  the  child.  When  the  baby  was  born 
a  deformity  of  the  face  was  found  which 
was  due  to  an  abnormal  production  of 
a  soft,  clastic,  uniform,  and  indolent  tis- 
sue, which  spread  from  the  zygoma  to 
the  external  commissure  of  the  eyelids 
and  back  to  the  insertion  of  the  ear 
posteriorly  from  the  mastoid  process  to 
the  inferior  border  of  the  thyroid  carti- 
lage. A  number  of  these  eases  observed, 
and  the  explanation  advanced  is  that, 
streptococci  having  found  their  way  into 
the  fcetal  circulation  through  the  pla- 
centa, an  inflammatory  process  was  set 


ELEPHANTIASIS.     PATHOLOGY. 


657 


up  in  tlie  foetal  tissues,  resulting  in  the 
overgrowth  of  tissue.  Jloncorvo  (Pedi- 
atrics, Dec.  1,  '97). 

Two  cases,  one  certainly  preceded  b}- 
syphilis  and  the  other  accompanied  with 
symptoms  which  were  in  all  probability 
tertiary;  in  both  excellent  results  were 
obtained  by  iodide  of  potassium,  in  one 
after  amputation  of  the  enlarged  left 
labium.  In  the  great  majority  of  in- 
stances chronic  ulcerative  processes  of 
the  vulva  with  elephantine  thickening 
are  of  syphilitic  origin.  Bamberg  (Ar- 
chiv  f.  Cyniik.,  I3d.  Ixvii,  H.  3). 


Unilateral  clcpliaiiliasis  of  the  face  and 
neck.     {Moncorvo.} 

Pathology. — The  changes  of  elephan- 
tiasic  areas  are  more  directly  located  in 
the  subcutaneous  tissues,  the  upper  and 
lower  strata  alike  sharing  in  the  charac- 
teristic phenomena.  The  skin,  although 
presenting  tliese  changes,  is  more  mark- 
edlj'  alTccted  where  papillary  outshoots 
are  observed.  Upon  cutting  into  the 
afTectcd  areas  there  is  observed  a  yellow- 
ish or  grayish  mass,  which  in  some  places 
shows  a  resemblance  to  fnttv  nr  lardn- 


ceous  deposits,  while  in  others  gelatinous 
formations  are  simulated.  Exuding 
lymph  may  be  observed  at  many  points. 
The  changes  from  the  normal  are  of  a 
distinct  hypertrophy:  there  is  decided 
proliferation  of  the  epidermis,  with  hy- 
perplastic increase  of  the  corium,  while 
the  fibrous  elements  of  the  subcutaneous 
tissue  are  observed  in  hardened  bands  or 
meshes  or  noted  to  be  soft  or  liquefied. 
Distended  lymph  -  spaces  are  found 
throughout  the  microscopical  section. 
All  the  soft  parts,  the  blood-vessels, 
lymphatics,  nerves,  and  their  component 
parts,  as  well  as  the  bony  structures, 
share  in  the  general  enlargement  and 
cell-infiltration.  At  times,  the  muscles 
and  the  glandular  structures  of  the  skin 
participate  in  the  increase  of  size. 

Obstruction  is  clearly  the  influence  in 
■  the  production  of  elephantiasis.  The 
presence  of  the  Filaria  sanguinis  hom- 
inis  in  the  lymph-vessels  is  directly  the 
cause  in  endemic  varieties  of  this  condi- 
tion. Manson  states  that  the  parent- 
worm  occupies  some  portion  of  the 
lymph-trunk,  at  which  point  it  dis- 
charges the  ova  into  the  stream  of  lymph; 
these  are  then  carried  forward  to  some  of 
the  grandular  structures,  in  which  they 
find  a  lodgment.  When  hatched  they 
enter  the  general  circulation.  Abstracted 
from  the  blood  by  the  mosquito,  and 
deposited  again  into  a  water-stream, 
the  ova  again  reach  man  when  contami- 
nated water  is  employed.  The  more  ag- 
gravated the  symptoms,  the  more  numer- 
ous are  the  parasites  in  the  lymph-chan- 
nels. Haamorrhage  and  discharge  of 
lymph  may  be  observed  in  these  types. 

In  sporadic  types  of  the  affection,  in 
which  the  obstruction  may  be  induced 
through  encroachment  of  large  tumors 
or  other  forms  of  pressure  upon  the  veins 
nnd   lymphatics,  the  same   features  are 


658 


ELEPHANTIASIS.    PROGNOSIS.    TKEAXJMENT. 


developed.  Although  they  are  iudistin- 
guishable,  there  is  no  mistaking  the  con- 
dition. Eczema  of  a  most  chronic  vari- 
ety, frequent  attacks  of  erysipelas  or 
other  forms  of  deep  dermatitis,  as  well 
as  tight  bandaging  of  a  part  may  also  be 
the  inducing  factors. 

Prognosis. — Although  the  disease  does 
not  tend  to  shorten  life,  much  discom- 
fort, as  well  as  intercurrent  maladies, 
may  place  the  affected  person  in  an  un- 
enviable condition.  Endemic  cases  may 
be  greatly  benefited  by  a  change  from  a 
malarious  or  sea  district.  Sporadic  types 
are  likewise  improved  by  change  of 
climate.  The  discomfort  may  alone  be 
caused  by  the  weight  of  the  affected  part, 
which  may  often  be  removed  by  surgical 
measures,  thus  insuring  relief.  Early 
cases  should  be  immediately  removed  to 
other  regions;  if  this  is  done,  a  favorable 
result  will  be  reached  early.  This  step 
often  arrests  even  cases  of  long-standing. 

Treatment. — In  endemic  cases  which 
are  preceded  by  the  preliminary  fever, 
with  its  accompanying  phenomena,  re- 
course must  be  had  to  the  measures  gen- 
erally adapted  to  most  febrile  manifesta- 
tions. Salines,  acetanilid,  quinine,  and 
cinchona,  which  influence  miasmatic 
fevers  and  their  consequent  complica- 
tions, should  be  administered.  Tonics 
will  be  demanded  in  many  cases  in  which 
the  depressing  effects  of  recurrent  at- 
tacks of  erysipelas  or  deep  inflammations 
are  experienced.  Codliver-oil,  with  or 
without  the  hypophosphites,  iron,  strych- 
nine, certain  mineral  acids  (hydrochloric 
or  sulphuric),  and  possibly  arsenic  may 
be  found  beneficial.  Again,  all  complica- 
tions should  be  remedied  as  they  appear 
in  the  several  cases  encountered.  All 
cases  of  this  affection  should  be  removed 
from  countries  in  which  the  disease  is 
endemic  or  where  malarial  or  other 
miaBmatic  atmospheres  are  found.    Spo- 


radic cases  are  to  be  removed  as  well  to 
some  healthy  climate.  Iodine  (or  its 
preparations)  and  mercury  have  been 
recommended  for  their  absorbent  quali- 
ties. Sterilization  of  drinking-water  at 
all  times  may  have  an  indirect  influence 
in  the  prevention  of  this  disease. 

Surgical  interference,  of  one  kind  or 
another,  may  be  productive  of  some 
fairly-good  results.  Large  growths  of 
enormous  weight  have  been  removed  by 
this  means.  The  penis  and  testicles  have 
been  restored  to  their  normal  conditions 
in  a  large  number  of  cases. 

Series  of  sixty  operations  successfully 
performed.  The  weight  of  the  tumors 
varied  from  one  and  a  half  to  thirty- 
nine  pounds.  The  usual  incision  is  made 
along  the  penis,  which  is  thoroughly 
decorticated;  and  by  vertical  incisions 
over  the  cords,  down  to  the  fundus  of 
the  tumor,  the  testicles  are  enucleated, 
and,  all  blubbery  material  being  care- 
fully removed,  the  organs  are  placed  on 
the  pubes  in  a  wrapping  of  gauze.  The 
upper  ends  of  the  vertical  incisions  are 
joined  to  the  wound  over  the  penis. 
Lateral  oblique  incisions  are  made 
through  healthy  skin  and  fat  along  the 
sides  of  the  tumor;  they  pass  down- 
ward, so  as  to  meet  just  in  front  of  the 
anus.  The  mass  is  then  carefully  dis- 
sected off,  exposing,  on  its  removal,  the 
accelerator  urina;  in  the  middle  and  the 
limbs  of  the  pubic  arch  at  the  sides.  All 
bleeding  vessels  are  ligatured.  One  now 
sees  the  decorticated,  but  turgid,  penis; 
the  testes  with  cords  of,  it  may  be, 
eighteen  inches'  length;  and  a  large 
triangular  wound,  fairly  representing  the 
superficial  dissection  of  the  anterior  halt 
of  the  perineum.  The  akin  and  fat 
bounding  the  wound  on  cither  side  are 
raised  up  from  the  fascia  lata,  over 
llie  hamstrings,  for  a  distance  of  about 
three  inches.  The  testes  arc  united  to 
each  other  in  the  middle  line  by  three 
or  four  interrupted  sutures.  The  edges 
of  the  sliding  lateral  (laps  are  then 
brouglit  together  over  the  testes  by  a 
series  of  strong  quilt-sutures.  The  penis 
ia  covered   by  the  anterior  end  of  the 


ELEPHANTIASIS. 


659 


tliigh-flaps,  and  by  Haps  raised  from 
above  the  pubes,  with  or  without  the 
addition  of  Thiersch  grafts.  Tlie  whole 
wound-area  is  dusted  with  iodoform, 
and  covered  with  suitable  dressings,  it 
is  essential  that  the  dressings  be  kept 
in  place  by  well-applied  bandages.  Heal- 
ing takes  place  throughout  by  first  in- 
tention in  about  eight  days.  Havelock 
Charles  (Indian  Med.  Record,  No.  5, 
'97). 

The  cicatrical  tissue  following  this 
treatment  always  gives  a  protective  cov- 
ering to  the  structures.  Surgeons  have 
abandoned  the  use  of  the  ligature  be- 
■cause  of  the  likelihood  of  causing  more 
disturbances  to  the  already-obstructed 
■circulation.  The  method  of  treatment 
generally  resorted  to  by  surgeons  at  the 
present  day  is  compression.  This  may  be 
considered  as  equal  in  value  to  ligature, 
•but  it  is  less  likely  to  provoke  other  con- 
ditions likely  to  promote  enlargement. 
Pressure  may  be  applied  by  the  use  of 
■some  form  of  bandaging.  Elastic  band- 
ages, such  as  those  advocated  by  Martin, 
or  ordinary  muslin  of  close  texture,  to  in- 
sure firmness,  may  be  applied  to  the  en- 
larged areas,  beginning  at  its  lower  and 
approaching  the  upper  part  in  gradual 
pressure.  This  means  has  been  followed, 
however,  by  untoward  consequences, 
such  as  gangrene  at  one  point  or  an- 
-other,  and  should  be  carefully  watched. 

Marked  success  from  hypodermic  in- 
jections of  calomel  in  a  case  of  elephan- 
tiasis in  a  woman  39  years  old.  Al- 
though the  patient  developed  symptoms 
of  syphilis,  yet  the  latter  occurred  after 
the  appearance  of  elephantiasis.  The 
author  concludes  that  intermuscular  in- 
jections of  calomel  have  a  beneficial  ef- 
fect on  elephantiasis,  but  they  must  be 
continued  for  a  considerable  time,  with 
frequent  interruptions.  Tiptseff  (Medit- 
zinskoje  Obozrenije,  vol.  Ivii,  No.  9, 
1902). 

J.  Abbott  Cantrell, 

Philadelphia. 


EMPHYSEMA.  See  Pulmonary  Em- 
physema and  Index. 

EMPYEMA,  THOKACIC— Empyema: 

GT.,i-u7ii'ch',  to  suppurate. 

Definition. — Empyema  is  an  accumu- 
lation of  pus  in  the  pleural  cavity  inde- 
pendent of  the  lung-tissue. 

Varieties. — The  various  Icinds  of  sup- 
purating pleurisies  are  pulsating  em- 
pyema, multilocular  empyema,  tubercu- 
lous empyema,  double  empyema,  putrid 
empyema,  and  interlobular  pleurisy. 

A\Tien  a  collection  of  pus  is  so  situated 
as  to  be  synchronous  with  the  heart-beat, 
it  is  denominated  pulsating. 

In  cases  of  pleuritic  adhesions  and  the 
circumscribed  diaphragmatic  pleurisy, 
we  often  have  encysted  collections,  which 
are  usually  many  in  number.  Tubercu- 
lous empyema  occurs  in  scrofulous  sub- 
jects and  is  often  localized,  with  caseous 
masses.  Double  empyema  occurs  simul- 
taneously on  both  sides,  while  interlobar 
pleurisy  is  the  inflammation  in  the  vis- 
ceral pleura,  or  that  covering  the  lung, 
and  pyajmic  exudation  accumulating  in 
the  interlobar  fissures. 

The  interlobar  empyemas  are  not  pri- 
marily abscesses  of  the  lungs,  but  of  the 
pulmonary  pleura;  but  necessarily  as- 
sume the  form  of  abscesses  of  the  lung  if 
not  circumscribed  by  adhesions  or  evac- 
uated early.  Tiie  putrid  empyema  is  a 
form  resulting  from  neglect  and  long  ex- 
posure to  the  various  pyogenic  micro- 
organisms, such  as  saprophytes,  and  the 
streptococci  and  staphylococci,  resulting 
in  pyjemia  and  septicemia. 

Symptoms. — In  most  cases  of  empy- 
ema there  is  a  history  of  exposure  to 
dampness  or  overheating.  A  chill  comes 
on,  then  fever,  and  pain  in  the  side.  The 
disease  may  not  have  been  regarded  as 
serious  or  a  relapse  may  have  occurred. 
In   a   few   days  dyspnoea   and   unusual 


660 


EMPYEilA.     SYMPTOMS. 


restlessness  call  the  attention  of  the  pa- 
tient again  to  his  chest.  In  a  month  or 
two  the  clinical  picture  has  gradually 
changed;  the  patient,  perhaps  florid  and 
plethoric,  may  have  become  emaciated 
and  morose,  a  short  loose  cough  suggest- 
ing the  presence  of  consumption,  which 
apparently  becomes  confirmed  when 
night-sweats  are  noticed.  The  aspect  of 
the  face  and  the  posture  is  that  of  ex- 
treme exhaustion.  The  physical  signs 
are  pain  in  the  side  affected.  This  may 
be  one  of  the  first  s)'mptoms;  but  the 
most  marked  of  these  is  discomfort  due 
to  dyspnoea  and  to  the  absorption  of  pus. 
The  skin  may  be  clammy  and  bathed 
in  a  cold  perspiration.  The  respiration 
is  about  40  to  the  minute;  temperature 
from  103°  to  105°.  There  is  dullness  on 
the  affected  side,  with  change  of  sound 
under  auscultation  and  percussion  when 
sitting,  when  lying  down  on  the  back,  or 
if  the  patient  be  turned  on  one  side. 

Twenty  patients  examined  with  spe- 
cial care  in  regard  to  the  change  of  level 
of  a  pleuritic  exudation  as  the  patient's 
position  is  altered.  Anything  that  might, 
by  acting  as  a  damper  upon  the  thorax- 
wall,  give  rise  to  apparent  dullness,  such 
as  pillows,  mattress,  supporting  hands 
placed  against  the  back,  etc.,  was 
avoided,  many  of  the  apparent  changes 
in  the  level  of  dullness  being  due  to  these 
agents.  The  thorax-wall  must  be  set  in 
vibration  and  give  cliaracter  to  the  per- 
cussion-sounds. If  a  damper  is  so  ap- 
plied as  to  stop  these  vibrations,  a  dull 
note  results.  A  normal  thorax,  if  per- 
cussed in  the  position  a  pleuritic  patient 
assumes,  will  give  a  dull  note  on  certain 
lines.  In  only  one  case  out  of  the 
twenty  did  the  examination  reveal  any 
change  in  the  line  of  dullness.  Strauch 
(Virchow's  Archiv,  June  1,  '89). 

liy  far  the  most  important  aid  in  diag- 
nosing that  empyema  has  followed  pneu- 
monia is  the  temperature.  The  usual 
thing,  if  empyema  follow,  is  for  the  tem- 
perature to  fall  when  the  crisis  takes 
place,  for  it  to  remain  down  two  or  three 


days,  for  it  then  to  rise  again,  so  that 
it  soon  becomes  from  2  to  4  or  5  degrees 
above  normal  in  the  evening  and  about  1 
or  2  degrees  in  the  morning;  this  con- 
tinues until  the  pus  is  evacuated.  Some- 
times the  apyrexial  interval  is  only  one 
day,  sometimes  it  is  four  or  five  days, 
and  sometimes  there  is  not  strictly  an 
apyrexial  interval,  for  the  temperature 
does  not  fall  at  the  crisis  to  normal,  but 
only  to  nearly  normal,  and  then  soon 
begins  to  rise  again,  so  that  instead  of 
an  apyrexial  interval  we  have  an  inter- 
val of  lower  temperature.  There  is  a  fall 
of  temperature  at  the  pneumonic  crisis 
with  a  subsequent  rise  in  about  a  third 
of  all  the  cases  in  which  empyema  fol- 
lowed pneumonia. 

In  many  cases  there  is  no  apyrexial  in- 
ter\-a!,  and  probably  in  some  of  these 
pus  is  present  from  quite  early  in  the 
illness.  W.  Hale  White  (Lancet,  Nov. 
10,  1900). 

Empyema  in  children  usually  follows 
lobar  pneumonia,  after  a  varying  inter- 
val. The  infection  is  usually  with  the 
pneumococcus.  Spontaneous  cure,  even 
when  aided  by  tapping,  is  rare.  Opera- 
tion should  not  be  delayed,  as  time  lost 
is  strength  lost,  and  the  issue  is  largely 
one  of  nutrition.  The  best  form  of 
operation  is  in  general  the  subperiosteal 
resection  of  an  inch  of  the  eighth  or 
ninth  rib  in  the  posterior  axillary  line, 
the  evacuation  of  pus  and  fibrin  masses, 
and  tube-drainage.  Irrigation  at  or 
after  operation  is  not  usually  advisable. 
Routine  after-treatment  in  fresh  cases 
should  be  tube-drainage,  the  tube  being 
progressively  shortened,  and  removed 
when  the  cavity  is  nearly  healed.  Where 
failure  to  heal  seems  to  depend  on  fail- 
ure of  the  lung  to  re-expand,  treatment 
by  valve  or  suction  apparatus  is  indi- 
cated. This  is  especially  of  value  in  the 
more  chronic  eases.  The  mortality  is 
about  one  in  seven;  in  small  children 
it  is  much  greater  than  in  those  over 
five  years.  The  causes  of  mortality  are, 
in  the  main,  beyond  our  control.  The- 
great  majority  of  cases  heal  even  when 
tlio  healing  is  delayed  for  many  months. 
(Chronic  empyema,  in  the  strict  sense,. 
is  rare  in  children.  The  closure  of  the 
cavity  depends  mainly  on  nutrition  and 


EMPYEMA.     SYMPTOMS. 


661 


on  adequate  drainage.  Recurrence  may 
take  place  from  faulty  drainage  at  any 
time,  and  it  may  occur  years  after  ap- 
parently sound  healing,  without  obvious 
cause.  Deformity  of  the  chest  is  usually 
temporary,  and  yields  to  treatment. 
Long-continued  discharge  from  the  cav- 
ity is  not  infrequently  followed  by  chest 
deformity  and  scoliosis  of  a  severer  type, 
permanent,  and  sometimes  extremely  se- 
vere. Cotter  (Boston  Med.  and  Surg. 
Jour.,  July  17,  1902). 


fremitus  on  the  affected  side.  If  a 
finger-tip  of  the  left  hand  is  held  in  an 
intercostal  space  over  the  region  and  a 
finger-tip  of  the  right  hand  is  held  in  a 
corresponding  intercostal  space  on  the 
sound  side,  and  the  patient  is  told  to 
count  audibly,  no  sound-waves  seem  to 
be  transmitted  to  the  finger  placed  in  the 
intercostal  space  on  the  affected  side,  and 
the  fin^rer  on  the  sound  side  feels  the  im- 


Lower  part  of  thoracic  walls  on  the  right  side.  A,  pectoralis  major; 
B,  pectoralis  minor;  C,  serratus  magnus;  D,  external  oblique;  E,  rectus  ab- 
dominis; 3,  third  costal  cartilage;  4,  fourth  costal  cartilage;  5,  5,  fifth  costal 
cartilage;  6,  6,  sixth  costal  cartilage;  7,  seventh  costal  cartilage;  8,  eighth 
costal  cartilage;  9,  ninth  costal  cartilage;  *,  placed  just  above  Mr.  Marshall's 
spot;  t,  aponeurosis,  common  to  external  oblique  and  pectoralis  major  and 
covering  rectus;    J,  xiphoid  appendix. 


Skodaic  resonance  is  a  term  used  to 
indicate  Skoda's  discovery  of  an  area 
near  the  clavicle  which  is  always  free 
from  the  extreme  flatness  found  in  em- 
pyema,— unless  this  area  be  also  invaded 
in  cases  where  the  dullness  is  found  in  all 
portions  of  the  chest,  in  which  case  the 
cavity  is  full  of  pus.  This  is  also  accom- 
panied by  a  disappearance  of  the  vocal 


pact  or  vibratory  motion  communicated 
through  air  by  the  sound-motion.  The 
sjTnptoms  of  serous  effusion  vary  slightly, 
and  yet  this  wave-motion  may  be  com- 
municated better  by  serum  than  by  pus. 
The  variety  of  sounds  heard  in  the 
early  stages  of  pneumonia  upon  ausculta- 
tion is  followed  by  a  complete  loss  of 
sound  on  the  affected  side  in  empyema. 


662 


EMPYEiLi.     SYMPTOMS. 


The  respiratory  murmur  is  nil.  The 
bronchial  murmur  above  may  be  per- 
ceptible. 

The  most-marked  cases  are  the  only 
ones  in  which  all  of  these  signs  and 
B3rmptoms  obtain;  for,  with  a  small  ac- 
cumulation of  pus,  very  little  more  than 
the  rise  of  temperature  and  dyspnoea 
exists.  The  final  termination  of  a  case 
not  recognized  and  treated  would  be  a 
pointing  and  rupture  externally  or  in- 
ternally. The  most  usual  points  of  rupt- 
ure have  been  the  weakest  and  least  re- 
sietant:  i.e.,  internally,  above  into  the 
bronchi  or  trachea;  and,  externally,  at 
the  free  spots  of  Marshall  or  of  Traube. 
The  point  on  the  right  side  which  is  com- 
paratively free  from  muscular  covering 
is  called  the  free  spot  of  Marshall,  while 
that  on  the  left  side,  as  in  this  case,  is 
called  the  region  of  Traube.  (See  wood- 
cut.) 

[The  spontaneous  discharge  of  em- 
pyema without  any  untoward  results 
was  observed  by  me  in  the  case  of  a 
young  girl,  aged  8  years,  who  had  been 
attacked  with  influenza,  and,  later,  with 
severe  pleurisy,  accompanied  by  high 
temperature,  weak  and  rapid  pulse, 
night-sweats,  and  hectic,  showing  great 
absoi-ption  of  pus.  In  the  course  of  time, 
a  prominence  about  the  size  of  a  hen's 
egg  was  noticed  on  the  right  side  near 
the  costal  cartilage.  After  a  simple 
incision  the  pus  was  fully  evacuated 
through  the  opening,  which  remained 
patulous  for  about  three  years.  The 
examination  of  the  patient  now  shows 
a  slight  lateral  curvature  of  the  spine, 
with  a  lack  of  development  of  the  mam- 
mary gland  on  the  right  side,  but  with 
a  considerable  cliest  expansion  and  very 
Blight  impairment  of  the  lung.  The  pa- 
tient is  rapidly  developing  into  woman- 
hood and  has  regained  her  health  and 
strength. 

The  discharge  of  pus  in  the  left  side 
was  observed  by  me  in  a  boy  at  Annis- 
ton,  Ala.,  in  whom  a  serous  pleural  ef- 
fusion bad  been  aspirated,  and  had  been 
treated  by  niodifntlon  nlso.     The  degen- 


eration of  serous  exudation  into  pus  was 
verified  in  this  ease.  Osier  has  stated 
that  he  has  never  seen  a  case  of  sero- 
fibrinous effusion  degenerate  into  puru- 
lent pleurisy,  but,  according  to  W.  M. 
Pirt,  literature  shows  many  similar  cases, 
The  region  at  which  the  pointing  oc- 
curred in  this  case  was  in  the  left  inter- 
costal space,  immediately  below  the  apex 
of  the  heart.  I  performed  the  operation 
of  resection  of  a  portion  of  the  sixth 
costal  cartilage  on  the  left  side,  and  se- 
cured drainage  with  a  strip  of  gauze 
passed  daily  through  the  fistulous  tract. 
The  patient  made  a  good  recovery,  also; 
and,  being  young  and  vigorous,  over- 
came the  tendency  to  scoliosis.  Tlie  last 
report  from  him  showed  that  there  had 
been  no  redevelopment  of  pus,  and  that 
the  fistula  had  been  closed.  J.  Mc- 
Fadden  Gaston.] 

The  Marshall  and  Traube  regions  are 
points  of  least  resistance  and,  although 
higher  than  the  pus  sometimes  reaches, 
may  be  considered  the  most  available  for 
spontaneous  discharge.  It  is  for  this 
reason,  and  because  the  region  of  Traube 
is  least  liable  to  complications  with  the 
diaphragm,  pleura,  and  abdominal  wall, 
that  Jaccoud,  of  Paris,  selected  it  for  the 
introduction  of  a  trocar.  J.  H.  Cox  has 
reported  a  case  in  which  spontaneous 
evacuation  took  place  in  front  between 
the  sixth  and  seventh  ribs.  Recovery 
followed. 

The  pus  may  discharge  through  the 
intercostal  spaces,  but  fail  to  reach  the 
surface  at  the  point  on  account  of  mus- 
cles; then  it  burrows  beneath  them.  In 
regard  to  the  spontaneous  escape  of  pus 
in  thoracic  empyema,  a  case  has  been  re- 
ported in  which  it  took  place  at  the  um- 
bilicus. This  location  of  tbc  weak  point 
is  a  corroboration  of  tlie  theory  that  pus 
escapes  at  the  point  of  least  resistance, 
and  not  always  at  the  point  of  the  lowest 
pressure.    (J.  G.  Willis.) 

[I   witnessed   the  case   of  a   man    at 
the  Atlanta  Polyclinic,  who  had  a  whole 


EMPYEMA.     DIAGNOSIS.     ETIOLOGY. 


663 


quart  evacuated  from  the  incision  made 
into  an  axillary  abscess  communicating 
witli  an  empyema.    The  patient  was  lost 
sight  of  after  the  first  evacuation  by  me, 
and  it  is  supposed  that  he  must  have 
been    relieved    by    the    use    of   a    gauze 
drainage  and  packing  at  that  time.     J. 
McFadden  Gaston,  Jr.] 
Diagnosis. — The    diagnosis    may    be 
made  from  the  extreme  dullness  and  lack 
of  respiratory  sounds,  when  the  tempera- 
ture remains  elevated.    But  an  explora- 
tory puncture  is  advisable  to  determine 
definitely  a  case  of  empyema. 

Subphrenic  pyothorax  can  be  recog- 
nized by  the  results  of  high  and  low 
aspiration,  in  a  large  percentage  of  all 
cases.  High  punctures,  in  the  fifth  inter- 
costal space,  show  a  collection  of  pus 
or  serum,  while  low  punctures,  as  the 
eighth  intercostal  space,  yield  pus  which 
is  always  ichorous.  Scheurlen  (Charit6- 
Annalen,  vol.  xiv,  p.  158,  '89). 

Two  eases  of  pulmonary  abscess  simu- 
lating empyema.  KaufTmann  (Birming- 
ham Med.  Review,  Oct.,  '93). 

Case  of  subdiaphragmatic  abscess  con- 
taining pure  culture  of  bacillus  coli 
communis  observed  which  simulated  em- 
pyema. F.  Tilden  Brown  (N.  Y.  Med. 
Jour.,  Feb.  2!),  '90). 

In  the  New  York  Foundling  Hospital 
during  the  last  ten  years  there  were  82 
cases  of  empyema,  and  G9  of  these  were 
under  two  years  of  age.  In  28  cases 
there  was  no  involvement  of  the  lung. 
Clinically,  it  is  at  times  most  difficult 
to  diagnose  and  locate  the  pus.  In  oppo- 
sition to  the  course  of  empyema  in 
adults,  in  children  the  disease  is  short 
and  critical,  some  cases  dying  within 
forty-eight  hours,  and  the  mortality,  in 
all  cases  of  children,  is  very  high.  The 
rational  signs  are  the  same  as  those  of 
pneumonia,  and  the  only  positive  sign 
is  the  finding  of  pus  with  a  large  ex- 
ploring-necdlc.  Practically  all  pleural 
effusions  in  infancy  are  either  purulent 
from  the  beginning  or  soon  become  so, 
and  when  pus  has  been  found  drainage 
is  called  for.  D.  Bovaird  (Med.  News, 
Dec.  2.'?,  '99). 
Pleuritic  efTu.«ion  and  a  camified  or 
hepatized  lung  should  be  borne  in  mind, 


and  they  may  be  excluded  when  the  ex- 
ploring needle  reveals  pus. 

At  times  cases  of  empyema  may  be 
confounded  with  ordinary  intramural 
abscesses,  as  when  they  occur  near  the 
axilla,  and  are  incised.  We  have  found 
several  cases  among  negroes  treated  late 
and  who  had  been  neglected. 

Etiology. — Pleurisy  with  its  usual 
sequeltc  of  pleural  effusion  is  the  most 
common  etiological  factor.  The  inflam- 
matory complications  of  pneumonia  are 
also  among  the  causes. 

There  are  four  main  groups  of  cases 
of  empyema  in  children.  The  first  is  the 
metapneumonic,  the  diplococcus  pneu- 
monia: playing  chief  role  as  etiological 
factor.  In  the  second  group  the  only 
micro-organism  found  in  the  pleuritic  ex- 
udates is  the  staphylococcus  pyogenes  or 
a  streptococcus.  The  third  group  is  due 
to  the  tubercle  bacillus,  and  the  fourth 
is  the  so-called  putrid  or  fcetid  empyema. 
Henry  Koplik  (Med.  Record,  Jan.  25, 
'90). 

It  is  impossible  to  state  with  accuracy 
the  percentage  of  cases  in  which  pneu- 
monia is  followed  by  empyema,  but  it  is 
interesting  to  note  that  out  of  325  con- 
secutive cases  of  empyema  in  the  med- 
ical wards  of  Guy's  Hospital,  there  were 
41,  or  12.C  per  cent.,  in  which  it  ap- 
peared that  the  empyema  followed  a 
lobar  pneumonia.  W.  Hale  White  (Lan- 
cet, Nov.  10,  1900). 

Clinical  study  of  one  hundred  and 
tliirty-five  cases.  When  the  streptococ- 
cus is  present  and  is  due  to  suppurative 
or  pytemic  conditions  outside  the  chest, 
it  is  usually  of  a  virulent  type  and  has 
a  correspondingly  bad  prognosis.  In  the 
metapneumonic  eases  the  prognosis  of 
streptococcus  is  little  worse  than  that 
of  Innceolatus.  The  particular  organ- 
ism present  is  a  less  cogent  factor  in 
determining  the  need  of  operation  than 
the  fever,  prostration,  chills,  the  quan- 
tity of  pus-cells  present,  and  the  tend- 
ency to  refill  after  operation.  The  grad- 
ual development  of  pus  after  .successive 
aspirations  can  usually  be  predicted 
from    the    presence    of    streptococci    or 


664 


EMPYEMA.    PATHOLOGY.    PROGNOSIS. 


pneumocoeci  in  the  first  fluid  Avithdrawn, 
even  though  that  be  a  clear  serum.    But 
pus  may  also  appear  when  the  earlier 
tappings  are  sterile.     C.  F.  Withington 
(Boston  Med.  and  Surg.  Jour.,  Nov.  6, 
1902). 
Trauma  may  also  give  rise  to  the  effu- 
sion.    Tubercular  empyema  may  follow 
the  perforation  into  the  pleural  cavity  of 
a  tubercular  peripleuritic  abscess,  origi- 
nating in  a  tubercular  osteitis  of  the  ribs 
or  vertebrEe. 

Tuberculosis  is  thought  to  be  caused 
by  pleurisy;  on  the  other  hand,  Germain 
See  and  others  are  quoted  by  J.  C.  Cas- 
tillo, of  Lima,  Peru,  as  regarding  three- 
fourths  of  all  pleurisies  tuberculous  in 
their  origin. 

The  most  frequent  cause  of  pleurisy  is, 
as  has  been  said,  the  bacillus  of  Koch. 

Children  are  especially  liable  to  em- 
pyema following  pneumonia ;  pneumonia 
caused  empyema  in  50  per  cent,  of  per- 
sonal cases;   all  were  of  severe  type.    A 
tuberculous  family  history  exerts  little 
influence  on  empyema.     In  about  one- 
sixth  of  the  cases  the  empyema  was  sac- 
culated;   the   pneumococcus  was  found 
in   50   per  cent,   of  the  cases   in  which 
examination    was    made;     the    strepto- 
coccus in  22  Vj  per  cent. ;    the  staphylo- 
coccus in  8  per  cent.;    the  tubercle  ba- 
cillus in  4  per  cent.;    and  no  bacterium 
in  10  per  cent.    The  pneumococcus  pro- 
duced the  most  virulent  infection.    J.  A. 
Hartwell  (Med.  News,  July  13,  1901). 
Pathology. — When   the   inflammatory 
process  sets  in,  the  pleura  becomes  thick- 
ened, and  this,  besides  the  inhibition  of 
the   lubricating  secretions  that   occurs, 
gives  rise  to  a  friction-sound:  one  of  the 
first  symptoms  of  pleurisy  to  present  it- 
self, as  well  as  one  of  the  last  to  dis- 
appear. 

The  lubricating  fluid  is  rather  in- 
creased as  an  effort  on  the  part  of  nature 
to  repair  the  damage  done  to  the  surfaces 
by  their  congested,  uneven  thickening. 
This  fluid  becomes  gradually  so  plentiful 
that  at  times  it  is  sufficient  to  form  serous 


effusion.  If  the  inflammatory  product 
should  continue  or  if  pyogenic  microbes 
invade  the  cavity,  suppuration  results, 
and  we  have  empyema. 

Case  of  calcareous  empyema  followed 
by  death.  Post-mortem  the  lung  was 
collapsed  and  the  pleura  thickened  and 
coated  on  its  whole  internal  surface  by 
a  thick  crust  of  calcareous  deposit,  in- 
cluding the  upper  surface  of  the  dia- 
phragm. The  sour,  milk-like  odor  of  the 
discharge  toward  the  last  suggested  that 
lactic-acid  fermentation  was  taking  place 
within  the  cavity.  T.  Carwardine  (Bris- 
tol Medico-Chir.  Jour.,  Mar.,  '98). 

Report    of   81    cases    of   empyema    in 
children.     Examination  of  the  pus  was 
made  in  G9.     In  all  but  4  of  the  69  the 
diploeoecus   was   found,   either   pure   or 
in  combination  with  some  other  organ- 
ism.    P.   S.   Blaker    (Brit.   Med.   Jour., 
May  23,  1903). 
Prognosis. — Cases    seen    early    result 
favorably  under  proper  treatment;  hence 
the  rule  that  cases  of  empyema  should 
never  be  allowed  to  grow  old. 

Six  hundred  and  lifty-six  cases  of  em- 
pyema in  children,  with  one  hundred  and 
four  deaths.  The  younger  the  patient, 
the  greater  the  risk  of  fatal  termination. 
The  sooner  the  purulent  effusion  re- 
moved, the  quicker  the  recovery.  Dan- 
ger to  life  is  chiefly  due  to  complica- 
tions: pericarditis,  peritonitis,  septi- 
Cfemia.  Wightman  (Lancet,  Nov.  30, 
'95). 

Considerable  practical  prognostic  im- 
portance attaches  to  the  bacteriological 
study  of  the  pus  of  empyema.  Thus, 
empyema  in  childhood,  caused  by  the 
pneumococcus,  is  quite  benign  and  runs 
a  rapid  course  to  recovery,  while  that 
caused  by  the  streptococcus  runs  a  slower 
course  and  is  more  serious.  Tuberculous 
pleuritis  is  a  chronic  process  usually  ter- 
minating fatally,  or  lasting  for  years 
until  tuberculosis  or  an  intercurrent 
affection  carries  off  the  patient,  or  he 
gradually  succumbs  to  prolonged  hectic 
amyloid  disease  and  asthenia.  Errors  in 
diagnosis  may  be  caused  by  tlie  tendency 
to  RcdimcnlaUon  of  the  pus,  when  an  ex- 
ploring-nccdle  may  withdraw  clear  fluid 
from    the    upper   layer    instead    of   pus. 


EMPYEMA.    TItEATilENT. 


665 


Joseph    McFarland    (Pliila.    Med.    Jour., 
Sept.  8,  1900). 

Very  much  depends  upon  the  nature  of 
the  infection.    The  readiness  with  which 
tlie  compressed  or  retracted  lung  returns 
to  fill   the   cavity   marks  the   difference 
between  a  case   of   favorable  and  rapid 
progress  to  complete  healing  and  a  pro- 
tracted one,  ending  possibly  in  extensive 
rib  resection  with  deformity.     As  to  the 
bacteriology,  the  two  main  features  are 
the  comparative  frequency  of  staphylo- 
cocci and  the  rarity  of  the  diplococcus 
pneumoniae.    Some  doubt  must  remain  as 
to  the  exact  relationship  which  the  bac- 
teria bear  to  the  production  of  pus.    W. 
F.  Hamilton  (Montreal  Med.  Jour.,  Oct., 
1900). 
In  all  cases  the  most  serious  conse- 
quence of  the  affection  is  deformity,  and 
in  children  lateral  spinal   curvature   is 
likely  to  occur.    Pyasmia  and  septicaemia 
will  result  from  putrid  empyema;    and 
general  miliary  tuberculosis  may  follow 
a  localized  tuberculous  pleurisy  which 
becomes   purulent.      Eupture   into    the 
bronchi,  trachea,  lungs,  with  immediate 
death  from  suffocation,  or  into  the  stom- 
ach after  perforating  the  diaphragm,  are 
among  the  possibilities. 

Treatment. — The  satisfactory  results 
obtained  by  Murchison  in  the  treatment 
of  pleural  effusions  by  incision  would 
seem  to  point  to  the  surgical  treatment 
of  many  cases,  before  empyema  has  set 
in,  as  a  valuable  measure.  For  this  pur- 
pose also  the  use  of  blood-letting,  blis- 
ters, and  medication  may  be  employed 
to  abort  the  inflammatory  process  suffi- 
ciently early  in  the  progress  of  pleurisy 
that  an  empyema  need  not  follow.  Blis- 
ters and  purgation  with  salines  and  mer- 
curials should  be  actively  employed,  in 
order  that  the  parts  undergoing  inflam- 
matory changes  may  be  relieved  of  the 
fibrinous  element  of  the  blood,  tending 
to  retard  resohition.  Opiates,  and  espe- 
cially the  camphorated  tincture  of 
opium,  may  be  used  to  relieve  pain  and 


hasten  the  resolution.  Carbonate  of  am- 
monia, turpentine,  and  digitalis  are  all 
also  of  value. 

[I  would  strongly  urge,  especially  in 
children,  of  an  early  recourse  to  the  fol- 
lowing preparation; — 

1}  Hydrargyri  chloridi  raitis,  1  grain. 

Pulv.  ipecac,  tt  opii,  10  grains. 

Quininee  sulphatis,  10  grains. 

Pulv.  camphora;,  1  grain. 
M.     Divide   into   powders   No.   x. 
Sig. :    One  powder  every  two  hours. 
In  adults:  — 
R  Hydrargyri  chloridi  mitis,  6  grains. 

Pulv.  ipecac,  et  opii,  30  grains. 

Quinina;  sulphatis,  30  grains. 

Pulv.  camphorse,  6  grains. 
M.    Divide  into  capsules  No.  xij. 
Sig.:    Take  one   every  two   hours  in 
day-time,  and  two  capsules  at  intervals 
while  awake  at  night. 

This  should  be  followed  with  two 
tablespoonfuls  of  oil  and  one  teaspoon- 
ful  of  turpentine. 

The  bowels  are  thus  emptied,  and  the 
turpentine  has  a  beneficial  effect  upon 
the  bronchial  tubes. 

I  have  seen  many  cases  of  incipient 
pleurisy  aborted  in  this  way,  and  the 
most  alarming  symptoms  of  high  tem- 
perature and  rapid  respiration  controlled. 
J.  McFADDBaj  Gaston,  Jr.] 

The  full  and  free  evacuation  of  the 
pleural  cavity  is  not  expedient  when  the 
pressure  has  been  great,  and  the  lung  is 
pressed  upon  in  such  a  manner  as  to 
displace  the  heart.  In  such  a  case  the 
gradual  evacuation  by  aspiration  is  pref- 
erable. 

Aspiration  should  be  limited  to  one  or 
two  trials,  for  empyemas  of  the  meta- 
pneumonic type,  as  seen  in  children  and 
adolescents.  For  all  other  cases  free  in- 
cision and  drainage  are  indicated.  Ran- 
Bohofl  (Ohio  Med.  Jour.,  Aug.,  '93). 

Cases  in  which  pus  contains  large 
masses  of  lymph,  or  pus,  thick  and 
creamy,  heal  best.  OfTcnsivencss  of  pus 
does  not  much  infliience  healing.  Delay 
is  advisable  when  there  is  negative  press- 
ure in  the  pleura,  and  when  expansibility 


666 


EMPYEMA.    TRK\TMENT. 


of  the  lung  and  contact  of  layers  of 
pleura  can  be  induced  by  simple  aspira- 
tion and  cure  effected.  Otherwise  harm 
will  result  from  delay.  Resecting  a  piece 
of  rib,  free  incision  of  pleura,  and  con- 
tinuous drainage  indicated.  Pollard 
(Brit.  Med.  Jour.,  Nov.  2,  '95). 

In  children  chloroform  is  the  prefer- 
able anresthetic,  but  deep  narcosis  is 
contra-indicated,  owing  to  the  danger  of 
pus  being  drawn  into  the  other  lung 
from  a  ruptured  bronchus.  In  adults 
with  general  empyema  two  inches  of  the 
seventh  and  eighth  or  eight  and  ninth 
ribs  in  the  posterior  axillary  line  should 
be  resected.  In  children  the  same  length 
of  the  seventh  rib.  Simple  incision,  with 
our  present  knowledge,  is  rarely  ad- 
visable. The  operation  is  indicated  as 
soon  as  diagnosis  is  made.  Irrigation 
of  the  abscess-cavity  with  bichloride  so- 
lution, 1  to  5000,  or  carbolic  acid,  1  to 
100,  is  indicated,  unless  drainage  is  per- 
fect and  no  sepsis  is  present.  In  chil- 
dren the  solutions  may  be  weaker.  The 
mortality  from  the  empyema  proper  was 
15  per  cent,  in  personal  cases.  Earlier 
and  more  radical  treatment  would  re- 
duce it  to  one-half  that  proportion.  J. 
A.  Hartwell  (Med.  News,  July  13,  1901). 

The  best  method  of  securing  counter- 
pressure  and  antisepsis  at  the  same  time 
is  by  the  injecting  of  a  saline  solution 
through  the  one  tube 

Injections  of  pero.xide  of  hydrogen  in 
50-per-cent.  solution  puts  a  rapid  stop 
to  the  formation  of  pus  in  the  thoracic 
pavity,  and  has  been  strongly  recom- 
mended as  an  injection  in  empyema 
whenever  injections  must  be  used.  Edi- 
torial (.Tour.  Respiratory  Organs,  Sept., 
'89). 

The  safest  method  of  procedure  con- 
sists in  replacing  gradually  the  pleuritic 
exudate  by  an  innocuous  fluid:  a  solu- 
tion (O.Ofi  or  0.07  per  cent.)  of  sodium 
chloride  (common  salt).  After  with- 
drawal of  a  small  portion  of  the  exudate 
the  same  quantity  of  salt  solution  is 
introduced  into  the  pleural  cavity.  By 
repeating  this  operation  several  times, 
entire  exudate  may  be  replaced  by 
saline  solution.  The  injected  liquid  dis- 
appears by  reabsorption  as  fast  as  the 


lung  dilates,  and  the  consequences  of  a 
sudden  diminution  of  the  intrathoracic 
pressure  need  not  be  feared.     S.  Lewa- 
chew  (Times  and  Register,  Apr.  11,  '98). 
Immediate  relief  to  syncope  has  been 
secured  by  the  reverse  action  of  the  as- 
pirator and  the  injection  of  the  same 
fluid  which  has  been  drawn  out. 

The  practice  of  aspiration  in  cases  of 
empyema  has  still  a  great  number  of 
advocates,  and  it  is  probable  that  an  at- 
tempt to  evacuate  the  pleural  cavity  in 
this  way  is  attended  with  good  results 
when  resorted  to  early  in  the  progress 
of  suppuration. 

The  packing  of  the  cavity  with  iodo- 
form or  plain  gauze  in  order  to  secure 
drainage  has  been  advocated  by  Ranso- 
hoff,  Laplace,  and  other  surgeons.  The 
experience  of  most  practitioners  is  that 
a  pleural  sero-fibrinous  effusion  does  not 
often  degenerate  into  a  purulent  collec- 
tion, and  many  attribtite  the  pus  to  the 
failure  of  antiseptic  precautions  in  as- 
piration. 

In  several  cases  the  following  points 
of  interest  were  noted:  Although  the 
pleura  had  been  full  of  fluid  for  twelve 
months,  rapid  rc-expansion  oecuiTed. 
After  thirty-seven  tappings  the  fluid  be- 
came as  clear  as  at  first,  in  spite  of 
admittance  of  air.  The  advice  given  in 
text-books  to  abandon  paracentesis  after 
two  or  three  trials  should  be  modified. 
Tlicre  is  no  risk  if  the  operator  is  careful 
to  keep  the  instruments  aseptic.  West 
(Brit.  Med.  Jour.,  Apr.  27,  '95). 

Paracentesis  Thoracis.  —  Aspira- 
tion or  simple  puncture  with  a  long  hy- 
podermic needle  is  performed  as  fol- 
lows:— 

1.  The  skin  in  the  intercostal  space 
selected  is  cleansed  with  soap  and  warm 
water,  followed  by  alcohol,  and  a  car- 
bolic-acid solution  of  G  to  100. 

2.  The  needle  is  asepticized  by  passing 
through  an  alcohol-lamp. 

3.  The  skin  is  held  up  and  the  fact 
ascertained  that  there  is  space  enough 


EMPYEAIA.    TREATMENT. 


667 


between  the  upper  surface  of  the  rib  and 
the  course  of  the  needle. 

4.  The  needle  is  then  suddenly 
plunged  so  as  to  penetrate  the  pleura. 

0.  After  removal  of  the  needle  the 
wound  is  closed  with  collodion  and 
cotton. 

When  a  vacuum  instrument  cannot  be 
secured,  the  surgeon  should  use  devices 
at  his  command  in  preference  to  await- 
ing the  more  convenient  forms  of  appa- 
ratus. He  can  attach  a  rubber  tube  to 
a  trocar  and  cannula,  if  he  is  careful  to 
hold  the  finger  upon  the  outlet  of  the 
cannula  as  he  removes  the  stylet.  It 
would  be  well  to  insert  a  rubber  tube  into 
an  antiseptic  solution,  so  that  the  fluid 
may  be  carried  into  it,  and  no  concern 
need  then  be  felt  as  to  the  fluid  ceasing 
to  flow,  when  air  would  enter  if  the  ex- 
ternal orifice  of  the  tube  were  out. 

The  exact  directions  in  paragraph  No. 
3  are  based  upon  the  course  of  the  inter- 
costal artery,  which  is  in  a  groove  on  the 
inferior  surface  of  the  rib,  while  the  skin 
should  be  raised  so  that  a  valvular  open- 
ing shall  be  made.  When  the  needle  is 
removed,  the  puncture  is  not  open  con- 
tinuously and  shuts  out  the  air. 

The  thorough  preparation  of  a  patient 
even  for  so  simple  a  procedure  as  aspira- 
tion, is  necessary. 

The  best  and  most  efficacious  drug  is 
strychnine  nitrate  injected  hypodermic- 
ally  before  an  operation.  The  combina- 
tion of  V;s  grain  of  strychnine,  with  ^f^ 
grain  of  morphine,  Vk,o  grain  of  atro- 
pine, and  '/<  grain  of  cocaine  hydro- 
chlorate,  may  be  injected  preparatory  to 
aspiration. 

The  patient  is  placed  on  the  sound 
side,  and  the  arms  folded  over  the  chest, 
so  as  to  draw  the  scapulsc  away  from  the 
vertebra?.  This  afTords  a  safe  method  of 
selecting  the  interspace  between  the 
sixth  and  seventh  rib  in  the  posterior 


axillary  line.  It  may  be  found  at  the 
extreme  angle  of  the  scapula,  and  with  a 
space  comparatively  free  from  muscles, 
where  the  ribs  are  some  distance  apart. 
The  most  expedient  course,  however,  is 
to  count  the  ribs  also,  and  to  have  a 
needle  at  least  three  inches  in  length 
which  is  attached  to  a  Potain  or  Dieula- 
foy  aspirator. 

The  most  dependent  portion  of  the 
collection  should  be  selected  in  small  ac- 
cumulations. 

The  diaphragm  has  its  lowest  attach- 
ment behind  at  the  twelfth  rib  and  on 
the  sides  about  the  ninth  or  tenth,  but 
the  collection  of  pus  may  be  incapsulated 
so  as  to  present  definite  indications  for 
puncture  as  low  as  the  eighth  intercostal 
space  in  the  middle  axillary  line;  behind 
this  point,  we  may  find  the  ninth  inter- 
costal space  clearly  dull,  from  fluid.  In 
such  cases  the  area  of  pulmonary  reso- 
nance on  the  sound  side  should  be  care- 
fully noted  as  a  comparative  guide. 

The  diaphragm  has  been  shown  to  be 
higher,  if  possible,  in  some  cases  of  em- 
pyema, on  the  afCected  side,  than  on  the 
sound  side.  The  oigan  will  rise  when 
the  compression  is  removed;  hence  the 
advice  of  Stokes  to  go  above  the  eighth 
interspace  in  cases  of  resection,  incision, 
or  puncture. 

The  sixth  interspace  in  the  midaxil- 
lary  line  or  the  eighth  in  the  posterior 
axillary  line  near  the  border  of  the  latis- 
simus  dorsi  muscle  and  at  the  angle  or 
point  of  the  scapula  is  the  point  of  se- 
lection of  F.  S.  Dennis.  The  advisability 
of  the  three  operations  (thoracentesis, 
thoracotomy,  thoracoplasty)  depends 
upon  the  age  of  the  patient,  the  charac- 
ter of  the  fluid,  and  especially,  in  the 
latter,  upon  the  fact  that  it  may  be  a 
life-saving  operation.    CRoswell  Park.) 

IxcisiON. — It  is  advisable  to  have  all 
in  readiness  in  cases  where  empyema  is 


€68 


i:.\iP\\EiLA..     TRJiATilJCNT. 


suspected,  and  an  exploratory  puncture 
or  aspiration  is  made,  to  incise  at  this 
point  should  pus  be  found  to  exist. 

Especially  is  an  incision  necessary  in 
cases  -n-here  numerous  punctures  have 
been  necessary  to  find  the  pus.  It 
should  be  made  where  the  needle  is  and 
before  it  is  withdrawn.  A- groove  may 
be  made  in  the  needle  of  the  aspirator, 
as  suggested  by  Kebbel,  so  that  the  blade 
can  be  started  from  this  exact  point  as 
guided  to  the  pus  by  the  groove.  All 
Buch  incisions  should  be  near  the  upper 
border  of  a  rib. 

There  are  five  classes  of  cases  in  which 
surgical  interference  is  to  be  considered: 

1.  Large  cavities  in  which  the  lung, 
fastened  to  the  vertebral  column  by 
thick  false  membrane,  is  entirely  and 
permanently  collapsed.  In  these  cases 
the  operation  is  useless  and  dangerous. 

2.  Large  cavities  in  which  the  lung, 
though  condensed,  still  preserves  a  slight 
vesicular  murmur.  Intervention  is  then 
sometimes  useful,  particularly  in  young 
patients  and  when  the  cavity  does  not 
extend  beyond  the  third  rib.  3.  Cavities 
from  eight  to  twelve  centimetres  in 
diameter;  these  present  the  most  favor- 
able conditions  for  cure.  4.  Simply 
fistulous  tracts  of  greater  or  less  length; 
if  short  and  straight,  the  results  will 
probably  be  good;  the  prognosis  be- 
comes less  favorable  when  the  fistulse  are 
long  and  tortuous.  5.  Cases  in  which 
there  are  moderate-sized  cavities  with 
fistulous  tracts  communicating  with 
them;  in  these  the  prognosis  is  favor- 
able. Bouilly  (Revue  de  Chir.,  Apr.  10, 
•88). 

The  ordinary  drainage  tube  is  often 
responsible  for  the  continuance  of  dis- 
charge when  used  to  drain  the  pleural 
cavity,  its  mere  presence  acting  as  an 
irritant.     Brinkman  (Penna.  Med.  Jour., 
Jan.,  1903). 
The  method  of  simple  incision  in  the 
intercostal  space  parallel  with  the  ribs 
has  been  sufficient  often  to  allow  a  drain- 
age-tube to  be  inserted,  and  in  this  way 
many  have  found  that  the  resection  of 
ribs  is  unnecessary. 


Free  incision  when  done  early  is  very 
successful;  the  removal  of  a  portion  of 
a  rib  is  never  necessary  in  acute  cases, 
and  a  fatal  issue  at  any  age  is  rather 
a  result  of  the  neglect  to  recognize  the 
true  nature  of  the  case  than  of  the  op- 
eration itself.  Lewis  ilarshall  (Lancet, 
Dec.  21,  '95). 

Below  the  age  of  23  it  is  unnecessary 
in  empyema  to  remove  portions  of  ribs, 
but  above  that  age  it  is  essential  in  or- 
der to  insure  contraction  of  the  abscess- 
cavity.  In  urgent  empyema  it  is  best 
to  use  no  chloroform,  but  to  freeze  the 
skin  with  ehlorideof-ethyl  spray.  In  pa- 
tients above  23  portions  of  ribs  may  be 
removed  whenever  the  breathing  is  suf- 
ficiently relieved  to  bear  chloroform.  J. 
0.  Renton   (Practitioner,  Jan.,  '90). 

Simple  incision  of  the  chest-wall,  tho- 
racotomy, may  be  employed,  the  site  of 
the  incision  being  determined  according 
to  the  position  of  the  collection  of  pus. 
An  opening  in  the  lowest  part  of  the 
pleural  cavity  is  not  the  most  suitable. 
It  is  not  advisable  to  wash  out  the 
cavity,  at  the  time  of  operation  at  all 
events;  such  a  procedure  is  not  devoid 
of  danger.  The  more  efficient  way  of 
treating  an  empyema,  especially  in  chil- 
dren, is  to  incise  and  remove  a  portion 
of  a  rib.  A.  Primrose  (Canadian  Praot., 
Mar.,  '90). 

Empyemata  healed  by  expansion  of  the 
lung,  ascent  of  the  diaphragm,  and  con- 
traction of  the  chest-wall.  In  all  recent 
cases  there  is  more  or  less  complete 
re-e.\pansion  of  the  lung  on  the  with- 
drawal of  the  pressure  which  has  been 
exei-ted  by  the  fluid.  Full  expansion  in 
the  lung  should,  therefore,  be  main- 
tained at  the  time  of  the  operation.  J. 
E.  Winters  (Prac.  Med.,  Mar.,  '90). 

Valved  tube  successfully  used  for 
draining  the  pleural  cavity  after  incision 
in  empyema,  with  the  object  of  prevent- 
ing the  falling  in  of  the  chest-wall  and 
diminished  expansion  of  the  lung.  W. 
M.  Ilutlon  (Lancet,  London,  Feb.  0,  '97). 

Report  based  on  seventy-five  cases, 
observed  chiefly  in  St.  Mary's  Hospital 
for  Children.  In  simple  cases  the  treat- 
ment was  as  follows:  Excision  of  about 
one  and  one-half  inches  of  the  seventh 
or  eighth  rib  in  the  posterior  axillary 
line;   light  ether  anajsthcsia  is  usually 


EMPYEMA.    TREATMENT. 


66» 


employed;  tlie  purulent  coagula  are  re- 
moved; short  rubber  tubing,  cut  partly 
across,  doubled  and  held  by  large  safety- 
pins,  is  used  for  drainage;  abundant 
gauze  dressing  is  applied  and  changed 
when  saturated.  If  the  patient's  con- 
dition contra-indicates  general  antesthe- 
sia,  an  incision  into  the  chest  may  be 
made  between  two  ribs  under  eucaine 
ansesthesia.  Aspiration  is  only  used  to 
give  temporary  relief  to  patients  who 
are  in  great  distress  from  the  pressure 
of  the  fluid,  or  temporarily  to  relieve 
the  second  side  of  a  double  empyema 
after  the  first  side  has  been  opened.  The 
patients  are  allowed  out  of  bed  as  soon 
as  practicable,  and  the  expansion  of  the 
lung  is  encouraged  by  forced  expiration. 
Irrigation  is  only  used  where  there  is  a 
foul-smelling  discharge  from  necrotic 
lung-tissue.  Secondary  operations  are 
not  done  until  good  opportunity  has 
been  given  for  healing — usually  three 
or  four  months  should  have  elapsed 
after  the  primary  operation — and  if 
there  should  have  been  no  noticeable 
improvement  for  a  month.  In  the  sec- 
ondary operation  the  expansion  of  the 
lung  should  be  encouraged  by  incising, 
stripping  back,  and,  if  necessary,  re- 
moving portions  of  the  thickened  pul- 
monary pleura.  The  examination  of 
forty-four  cases  at  long  periods  after 
operation  indicates  that  recovery  is  usu- 
ally complete  in  the  simple  cases,  and 
that  there  is  surprisingly  little  deform- 
ity in  most  of  the  severe  cases.  Dowd 
(Medical  News,  Sept.  13,  1902). 

Alfred  Sheen,  of  Cardiff,  Scotland,  has 
been  successful  in  securing  permanent 
cures  by  the  method  that  we  have  out- 
lined above,  and  the  consensus  of  opinion 
seems  to  be  that  the  most  radical  meas- 
ures are  not  indicated.  When  resection 
is  practiced,  a  small-sized  piece  of  rib, 
sufficient  for  one  drainage-tube,  has  been 
found  to  answer  all  the  purposes  of 
drainage. 

The  most  important  and  at  the  same 
time  the  most  ingenious  operation  de- 
vised to  accomplish  this  has  been  by  Dr. 
Carl  Beck,  of  New  York.     lie  uses  an 


elevator  by  which  the  rib  may  be  cut  and 
denuded  of  periosteum  at  the  same  time. 
The  indication  for  the  operation  is,  of 
course,  in  children,  or  those  patients  in 
whom  a  drainage-tube  could  not  be  in- 
serted between  the  ribs.  The  indorse- 
ment of  John  Ashhurst,  of  Philadelphia, 
is  very  strong  in  favor  of  operative  inter- 
ference in  cases  of  empyema,  and  the 
mortality  he  reports  is  especially  small. 

The  practice  of  iacision  and  drainage, 
of  resection  of  ribs  with  the  insertion  of 
drainage-tubes,  of  the  siphon-apparatus 
introduced  by  Biilau,  all  subserve  the 
purpose  intended. 

Thoracotomy  performed  in  76  cases 
of  empyema,  of  which  89  per  cent,  were 
cured;  about  71  per  cent,  were  able  ta 
work  within  two  months.  The  point  of 
election  for  the  incision  is  the  lateral 
surface  of  tlie  thorax,  just  below  the 
axilla,  selecting  the  fourth,  fifth,  or 
sixth  rib.  A  tube  carried  in  at  such- 
point  will  always  enter  the  free  cavity, 
and,  with  the  patient  in  the  proper  lat- 
eral position,  allow  the  pus  to  flow  out, 
a  portion  of  the  rib,  about  1  Vio  inches, 
being  previously  removed.  If  disin- 
fectant washes  are  indicated,  salicylic- 
or  boric-  acid  solutions  are  preferred.  A 
bandage  covering  the  whole  thorax  is 
used,  in  connection  with  special  move- 
ments of  the  body  and  rest  in  bed  on 
the  side,  inclining  to  the  back.  Koenig^ 
(Pittsburgh  Med.  Review,  Oct.,  '91). 

Even  if  the  operation  for  empyema 
does  not  effect  a  cure,  it  does  not  make 
the  patient  worse.  In  the  large  majority 
of  cases  operations  give  great  relief,  and 
in  a  certain  proportion,  particularly  in 
the  young,  they  give  a  perfect  cure. 
Very  rarely  do  they  cause  death.  J. 
Ashhurst  (Intemat.  Med.  Mag.,  June, 
■94). 

Costal  trephining  is  simple  of  per- 
formance and  harmless.  Preferably  per- 
formed on  eighth  and  especially  ninth 
rib  in  widest  portion,  posteriorly  seven 
centimetres  from  costal  angle.  Cromi  of 
trephine  one  centimetre  in  diameter. 
Several  openings  may  be  made,  either  in 


670 


EMPYEMA.     TREATMENT. 


the  same  or  adjacent  ribs.  Rev  (Lvon 
MM.,  June  23,  '95). 

In  operating  for  empyema  iu  children, 
circumscribing  of  the  inferior  and  poste- 
rior borders  of  the  healthy  lung  advised, 
followed  by  resecting,  on  the  diseased 
side,  the  rib  situated  two  or  three  centi- 
metres above  this  limit,  near  the  verte- 
bral column.  Sehultz  (Jahrb.  d.  Hamb. 
Staatskr.,  vol.  xiii,  p.  2G0'). 

Case  of  subphrenic  abscess  followed  by 
empyema  successfullj'  treated  by  resec- 
tion of  a  rib,  drainage,  and  packing. 
McNaught  {Brit.  Med.  Jour.,  May  22, 
■97). 

Generally  speaking,  the  case  should  be 
a  law  unto  itself,  and  the  surgical  means 
at  our  command  should  be  accompanied 
by  early  out-door  exercise  and  gymnastic 
performances,  especially  in  children  and 
young  adults.  The  deformity  sometimes 
following  the  operation  may  be  treated 
by  Sayre's  jury-mast,  and  by  the  ordi- 
nary remedies  and  measures  for  scoliosis. 

Skyphosis  or  Lordosis. — Since  1883, 
Dieulafoy  has  practiced  thoracentesis 
180  times  on  69  hospital  patients  and 
200  times  in  his  private  practice,  and 
never  once  has  he  seen  the  liquid  become 
purulent  after  the  operation.  Whenever 
the  liquid  reached  1800  grammes  (60 
ounces)  thoracentesis  was  imperative. 

Treatment  by  irrigation  of  the  pleural 
cavity  is  severely  condemned  by  most 
authorities. 

[The  employment  of  irrigation  in  the 
cavity  of  the  che.st  after  the  removal  of 
purulent  collection  by  incision  or  other- 
wise is  a  precarious  measure.  Even  ster- 
ilized hot  water  has  been  attended  with 
marked  vital  depression,  amounting  in 
some  eases  to  collajjse.  The  introduc- 
tion of  iodoform  with  glycerin  by  swab- 
bing over  the  surface  or  upon  gauze 
tampons  within  the  pleural  cavity  is 
not  attended  with  the  inconveniences  of 
general  irrigation,  and  proves  more  ef- 
fective in  correcting  septic  development. 
J.  McFadden  Gaston,  Assoc.  Ed.,  An- 
nual, '90.] 


Xumber  of  cases  of  empyema  with 
fistula  treated  by  warm  baths.  If  the 
fistulous  opening  is  below  the  level  of 
the  fluid,  it  is  evident  that  if  the  pa- 
tient inspires  and  expires  freely  there 
will  be  a  current  of  water  into  and  out 
of  the  pleural  cavity  much  stronger  than 
can  be  obtained  by  simple  irrigation. 
Clumps  of  coagulated  blood  and  fibri- 
nated  masses  are  by  this  means  washed 
out  which  could  not  have  been  removed 
by  simple  lavage.  The  baths  were  given 
in  boiled  water  cooled  to  the  temperature 
of  the  body,  and  lasted  ten  or  fifteen 
minutes.  The  general  condition  of  the 
patients  was  much  improved,  and  no 
accident  was  observed  to  follow  this 
treatment.  Zeman  (Rev.  de  Thfr.,  May 
1,  '97). 

Case  of  empyema  in  a  child  success- 
fully treated  by  irrigation  by  submer- 
sion, according  to  Zeman's  method,  after 
resection.  S.  S.  Adams  {Pediatrics,  July 
1,  '98). 

Irrigation  with  a  4-per-cent.  solution 
of  bicarbonate  of  sodium  used  in  a  case 
of  empyema  in  which  incision,  drainage, 
and  lavage  with  boric-acid  solution  had 
failed  to  prevent  reaccumulation  of  pus. 
Daily  irrigation  with  the  bicarbonate 
solution  for  five  days  eff'ected  a  cure. 
L.  Betances  (La  Revista  M&l.  de  Siinto 
Domingo,  Anno  1,  No.  2,  1902). 

Authors  agree  in  the  following  dan- 
gers in  aspiration  or  irrigation  of  the 
pleural  cavity,  viz.:  Hemiplegia,  follow- 
ing cool  solutions;  death  following  as- 
piration; fatal  results  also  in  cases  of  the 
use  of  an  anaesthetic;  unusual  depression 
from  the  sitting  posture  during  aspira- 
tion, relieved  by  assuming  the  reclining 
position.  The  cautions  given  have  been 
to  use  warm  solutions,  or,  better,  no  solu- 
tions at  all;  and  to  stimulate  with  cog- 
nac, strychnine,  etc.,  previous  to  thora- 
centesis. 

[Richard  II.  Harte,  of  Philadelphia, 
has  never  had  an  unpleasant  result  from 
washing  out  an  old  empyema;  but  it 
nuist  be  remembered,  ho  says,  that  a  oon- 
siderable  number  of  cases  are  on  record 
in  which  an  injection,  which  may  have 


KMPVJiJbV.     TKEATilENT. 


671 


been  frequently  repeated  willioiit  serious 
consequences,  has  led  to  sudden  death, 
or  to  the  most  alarming  symptoms,  prob- 
ably from  the  sudden  increase  of  press- 
ure within  the  cavity,  caused  by  a  par- 
tial closing  of  the  outlet  or  by  the  use 
of  too  large  a  tube.  The  nature  of  the 
fluid  employed  can  have  had  nothing 
whatever  to  do  with  these  results,  as 
equally  bad  results  have  followed  the 
use  of  pure  water.  ("International  En- 
cyclopaedia of  Surgery,"  Ashhurst,  vol. 
vii.  Supplement.) 

These  results  emphasize  the  risks  at- 
tending intrathoracic  irrigation.    J.  Mc- 
Fadden  Gaston.] 
Interlobar    Pleurisy. — This    form 
is  best  treated  by  the  excision  of  the  fifth 
and  sixth  ribs,  as  shown   in  examples 
treated  by  Segond  and  others.    The  sur- 
geons  who   have   discovered   interlobar 
pleurisies  in  time   for  treatment  have 
generally  made  their  resections  too  low. 
The    autopsies    in    some    cases    showed 
Rochard's  former  statement  correct  in 
regard  to  their  location. 

Most  published  cases  have  recovered 
without  operation,  the  pus  having  been 
expectorated. 

Case  operated  on  in  which  death  oc- 
curred some  days  later,  the  pus  being 
found  between  the  lobes  of  the  right 
lung.  Gerhardt  (Brit.  Med.  Jour.,  Sept. 
9,  '93). 

Cases  of  long  standing  with  fistulae, 
deformity,  and  great  rigidity  of  the  cos- 
tal walls,  may  require  what  is  known  as 
the  Leti^vant-Estlander  operation,  an 
operation  first  suggested  by  Letievant 
and  practiced  by  Estlander.  The  opera- 
tion has  been  variously  applied  to  any 
resection  of  ribs  for  the  purpose  of  the 
approximation  of  the  walls  of  the  chest. 
The  most  important  distinction  to  be 
made,  however,  is  that  originally  the  op- 
eration included  more  than  one  rib  and 
several  inches  of  length  in  the  resection. 
[Frederick  S.  Dennis  has  awarded  the 
credit  of  the  first  suggestion  of  resection 
of  the  ribs  to  Dr.  Warren  Stone,  of  New 


Orleans,  while  Dollingcr  (Annual,  '90) 
and  others  state  that  LctiC-vant  first 
suggested  it. 

The    two    suggestions  were  probably 
original  so  far  as  each  of  the  above  sur- 
geons were  concerned.    Many  operations 
have  been  done  in  this  way,  as  seen  in 
the  case  of  W.  W.  Keen.    J.  McFasder 
Gaston,  Jr.] 
The  operation  of  Schede  consistB  in 
the  complete  removal  of  the  muscles  and 
tissues  adherent  or  attached  to  the  ribs, 
with  the  exception  of  the  skin,  the  fascia, 
and  the  parietal  pleural,  and  these  are 
stitched  together  and  form  the  only  pro- 
tection to  the  chest  at  the  point  of  the 
operation,  and  the  only  hope  of  restoring 
the  tissue  lies  in  the  granulating  process. 
The  incision  is  a  U-shaped  one,  ex- 
tending from  the  axilla  in  front  down- 
ward to  the  limit  of  the  pleura  and  back- 
ward and  upward  to  the  second  rib,  lift- 
ing the  scapula  in  the  removal  of  the 
bony  flaps.    This  operation  has  been  ad- 
vised as  a  modification  of  Estlander's 
operation,  in  cases  where  the  pleura  is 
much  thickened  and  where  the  walls  fail 
to  respond  to  ordinary  means  of  reducing 
the  cavity  of  the  chest. 

Estlander's  operation — which  consists 
in  removing,  not  only  a  certain  length 
or  a  certain  number  of  ribs,  but  all  the 
ribs  lying  in  the  wall  of  the  empyema 
— performed  twelve  times,  the  results 
being  nine  cures  and  three  deaths,  one 
from  tuberculosis,  the  second  from  car- 
diac disease,  and  the  third  from  albu- 
minuria. J.  Boeckel  (Revue  Chir.,  Apr. 
10,  '88). 

Extensive  thoracoplasty  by  Schede's 
method  performed  in  a  case  of  thoracic 
empyema  of  twelve  years'  duration.  Sec- 
ond operation  performed  three  months 
after  first.  Recovery  was  without  inci- 
dent, though  slow.  Eight  months  after 
the  second  operation  the  wound  broke 
open  again  and  discharged  a  small 
quantity  of  pus.  By  a  third  operation 
some  more  of  the  chest-wall  at  the  upper 
posterior  angle  was  removed.  A  cavity 
three  and  one-half  inches  long  and  as 


672 


EilPYKMA.    TREATMENT. 


thick  as  the  thumb  was  found.  This 
was  nearly  obliterated  by  granulation- 
tissue.  W.  W.  Keen  (Annals  of  Surgery, 
June,  "95). 

One  hundred  and  twenty-nine  cases  of 
empyema  treated  by  resection  of  the 
chest-wall,  in  which  56.3  per  cent,  were 
healed,  20  per  cent,  improved,  3  per  cent. 


Fig.   l.^-Schede's  incision  for  thoracoplasty. 
{Keen.) 

unchanged,  and  20  per  cent.  died.  There 
is  little  oi"  no  tendency  to  spinal  curva- 
ture or  to  impairment  of  function  of  the 
corresponding  upper  extremity  follow- 
ing these  operations.  Voswinkel  (Deut. 
Zeit.  f.  Chir.,  B.  4.5,  S.  77). 

Deformity  observed  resulting  from  re- 
moval of  the  fourth,  fifth,  si.xth,  and 
seventh  ribs.  This  consisted  of  a  large 
depression  of  the  whole  left  side,  begin- 
ning about  two  inches  below  the  clavicle 
and  extending  below  the  free  border  of 
the  ribs.  There  was  a  marked  degree  of 
lateral  curvature.  L.  Emmett  Holt 
(Archives  of  Fed.,  Jan.,  '96). 

In  the  treatment  of  empyema  success 

obtained  by  removing  the  whole  of  the 

chest-wall  covering  the  cavity   (Schede) 

and  breaking  up  and  loosening  of  the 

contracted    pleura;    (Delorme).      Jordan 

(Med.  Record,  May  14,  '98). 

Christian  Fenger,  of  Chicago,  holds 

that   there   are  certain   cases   in   which 

Schede's  operation  is  required;  viz.,  after 

milder  measures,  such  as  incision,  drain- 


age, and  Estlander's  operation  have  been 
fruitlessly  employed.  He  reported  a  suc- 
cessful case  in  which  this  operation  was 
performed  after  other  measures  had  been 
unsuccessfully  resorted  to  during  seven 
years. 

Eoswell  Park,  of  Buffalo,  states  that 
the  treatment  of  empyema  should  be 
based  upon  the  same  principles  as  are 
applicable  to  other  abscesses.  In  acute 
cases  presenting  streptococcic  and  staphy- 
lococcic suppuration  it  may  be  sufficient 
in  a  few  instances  to  simply  aspirate.  A 
summary  of  the  treatment  to  be  em- 
ployed in  cases  of  empyema  may  include 
the  following  features: — 

(a)  Prophylaxis. 

1.  Care  should  be  taken  to  jugulate,  if 
possible,  all  cases  of  incipient  pneu- 
monia, pleurisy,  and  bronchitis. 


Fig.  2. — Schede's  incision  for  thoracoplasty. 
The  solid  line  sliows  tlie  incision  made  by 
Keen.  The  dotted  line  shows  the  portion  of 
the  bony  and  muscular  ehest-wall  removed. 
The  posterior  line  should  be  farther  back. 
{Keen.) 

2.  All  penetrating  wounds  of  the 
chest,  whether  from  gunshot  wounds  or 
stab  wounds,  should  be  hermetically 
sealed. 


EMPYEMA.    TREATMENT. 


673 


3.  Collections  of  blood-serum  or  air 
may  be  evacuated  early  by  aspiration. 

4.  Children  should  be  carefully  ex- 
amined in  cases  of  continued  fever, 
sweats,  and  hectic,  and  prompt  measures 
taken  to  remove  the  possibility  of  puru- 
lent collections,  by  exploration. 

(6)  Operative  treatment. 

5.  Incision  and  drainage. 

6.  Trap-door  for  exploration  in  cases 
of  tuberculous  deposits  of  caseous  ma- 
terial. 

7.  Estlander's  operation  for  the  old 
and  stubborn  cases  of  fistulous  empyema. 

8.  Schede's  operation  for  thickened 
pleurse,  and  resistance  to  the  recourse  to 
Estlander's  operation  or  to  Delorme's, 
Qu6nu's,  or  Gaston's  modifications  of 
flap-operations. 

9.  Iodoform  or  plain  sterilized  gauze 
tamponage  for  stimulating  the  granula- 
tion and  securing  constant  drainage. 

10.  Permanganate-of-potash  solutions 
for  offensive  discharges. 

Thfi  successful  results  which  have  fol- 
lowed Estlander's  and  Sehede's  opera- 
tions in  certain  severe  cases  of  empyema 
have  led  some  surgeons  to  take  the  too 
extreme  position  of  advocating  resection 
of  the  rib  in  all  cases.  Incision,  the 
insertion  of  a  drainage-tube,  and  irriga- 
tion with  mild  antiseptic  solutions  con- 
sidered as  the  treatment  most  suitable 
for  the  great  majority  of  cases.  Edmund 
Andrews  (Jour.  Amer.  Med.  Assoc,  Mar. 
4,  '99). 

Pulsating  Pleural  Effusions. — 
The  term  has  been  recognized  for  an  em- 
pyema occurring,  according  to  Tillmans, 
almost  entirely  on  the  left  side.  There 
have  been  sixty-eight  cases  collected,  and 
these  have  occurred  in  the  hands  of  a 
few  men.  The  only  mistake  that  might 
prove  fatal  could  be  to  open  a  thoracic 
aneurism,  thinking  that  it  was  an  em- 
pyema. The  general  indications  of  em- 
pyema may  be  conclusively  corroborated 
by  an  exploring  needle  or  aspirator.    The 


treatment  is  the  same  as  in  any  ordinary 
case  of  empyema. 

Tubercular  Empyema.  —  A  large 
proportion  of  the  cases  of  empyema  are 
essentially  cases  of  cold  abscess,  or,  more 
properly,  tuberculous  abscess.  In  these, 
free  incision,  free  drainage,  and  excision 
of  a  rib  are  required.  Park  has  resorted 
to  scraping  with  the  sharp  spoon,  and  in 
some  he  has  cauterized  the  diseased  sur- 
face with  a  50-per-cent.  solution  of  zinc 
chloride.     In  several  cases  death  would 


V 


k, 


Fig.  3. — Kesult 


yK, 


operation. 


have  occurred  had  it  not  been  for  some 

such  radical  operation. 

In  tulicrculous  oases  radical  operation 
indicated — thoracotomy  with  resection — 
if  exploratory  puncture  show  bacteria  of 
suppuration.  If  there  are  no  bacteria 
of  suppuration,  aspiration  advised  to 
relieve  pressure  and  allow  the  lung  to 
expand.  If  the  case  is  of  long  standing, 
and  the  compressed  lung  is  inexpansible, 
palliative  measures  are  indicated.  Baum- 
ler  (Deutsche  med.  \Voch.,  Xos.  37,  3S, 
•94). 
Tuberculous    purulent    pleurisy    has 

been  cured  by  thoracentesis  followed  by 


674 


EMPYEMA. 


ENCEPHALITIS. 


injections  of  corrosiye  sublimate  and 
boric  acid  through  the  same  needle  (or 
cannula)  of  a  Dieulafoy  or  Potain  as- 
pirator. 

To  summarize  the  treatment  of  em- 
pyema, the  following  propositions  seem 
tenable: — 

1.  Empyema  is  best  prevented  by 
promptly  evacuating  all  considerable  in- 
flammatory effusions. 

2.  In  the  diagnosis  of  these  effusions,  by 
means  of  exploratory  aspiration,  the  skin 
should  be  punctured  by  a  tenotome  at 
the  point  where  the  needle  is  to  be 
driven  in. 

3.  Serous  effusions  are  best  evacuated 
by  aspiration.  If  they  reaccumulate 
after  the  third  evacuation,  they  should 
be  subject  to  continuous  siphon-drainage, 
the  puncture  being  made  by  a  small  tro- 
car and  cannula,  the  latter  being  of  such 
size  that  a  small  drainage-tube  may  be 
slipped  through   it. 

4.  Recent  empyemata  are  best  treated 
by  continuous  siphon-drainage,  the  tube 
being  introduced  through  a  cannula  of 
at  least  the  diameter  of  the  little  finger. 

5.  When,  because  of  a  narrow  inter- 
costal space  or  because  of  constant  block- 
ing with  fibrinous  material,  siphon- 
drainage  thus  provided  is  inadequate,  an 
inch  of  one  of  the  ribs  (usually  seventh 
or  eighth)  should  be  resected,  and  a 
drainage-tube  the  diameter  of  the  thumb 
should  be  used. 

6.  When  the  conditions  are  such  that 
it  is  obviously  impossible  for  the  lung  to 
expand  under  the  influence  of  siphon- 
drainage  and  respiratory  exercises,  De- 
lomie's  operation  of  stripping  the  pseudo- 
membrane  from  the  compressed  lung 
should  be  attempted. 

7.  When  Delorme's  operation  is  im- 
practicable, a  resection  of  the  ribs  (Est- 
lander)  or  of  the  chest-wall  and  thick- 
ened pleura  (Schede),  corresponding  in 
extent  to  the  size  of  tlie  underlying 
cavity,  is  indicated.  Edward  Martin 
(Ther.  Gaz.,  Aug.  }5,  1900). 

Decortication  of  the  lung.  In  this 
operation  the  thickened  pleura  is  re- 
moved from  a  lung,  wliich  in  conse- 
quence of  a  pleural  exudate  has  been 
more  or  less  collapsed.    It  was  first  per- 


sonally used  in  1S93.  It  is  indicated  for 
old  empyemata,  in  which  there  is  no 
tuberculosis  of  the  lung  and  the  patient 
has  sufficient  strength  to  withstand  a 
major  operation.  It  is  a  better  opera- 
tion than  Estlander's,  as  by  it  there  is 
a  restoration  of  the  function  of  the  lung 
and  a  closure  of  the  suppurating  cavity. 
The  diseased  pleural  membrane  is  dis- 
sected away  —  not  only  that  which 
covers  the  lung,  but  that  portion  lining 
the  wall  of  the  thorax  and  covering  the 
diaphragm.  The  operation  should  be 
made  as  thorough  as  possible,  and  to 
this  end  a  large  opening  in  the  chest  is 
necessary.  It  should  be  so  made  as  to 
admit  of  rapid  closure  after  the  opera- 
tion, as  this  facilitates  expansion  of  the 
lung,  wliich  is  brought  about  by  respira- 
tory movements.  Respiratory  exercises 
should  be  employed  in  the  after-treat- 
ment. G.  R.  Fowler  (Med.  News,  June 
15,  1901). 

J.  McFadden  Gaston, 
J.  McFadden  Gaston,  Jr., 

Atlanta. 

ENCEPHALITIS.  —  Gr.,  eyx£<pa?iog, 
the  brain,  and  iTig,  inflammation. 

Synonyms.  —  Encephalitis;  cerebritis. 

Definition. — Inflammation  may  attack 
any  portion  of  the  brain,  and  in  some 
cases  nearly  the  entire  brain  is  afllected. 
It  is  probable  that  general  inflammation 
of  the  brain  never  occurs,  death  ensuing 
before  the  inflammatory  process  invades 
the  whole  brain.  Usually  the  inflamma- 
tion is  confined  to  a  more  or  less  cir- 
cumscribed area  in  one  lobe,  but  quite 
frequently  it  involves  an  entire  lobe,  less 
frequently  all  of  one  hemisphere,  or 
large  areas  of  both  hemispheres;  also  it 
may  exist  as  isolated  or  disseminated  foci 
throughout  the  organ.  No  age  of  life 
is  exempt  from  it,  and  a  prenatal  form 
is  descrilied.  It  is  also  frequently  asso- 
ciated with  meningitis. 

Encephalitis  may  cause  acute  or 
chronic  softening,  the  formation  of  pus, 
and  fotnplote  rlisinlogration  of  alTccted 


ENCEPHALITIS.    ACUTE  NON-SUPPURATIVE. 


675 


parts  of  the  brain;  or  it  may  cause  an 
acute  or  chronic  hardening  of  the  brain, 
with  or  without  atrophy,  and,  in  certain 
rare  cases,  hypertropliy  may  exist.  It  is 
thus  seen  that  tlie  term  encephalitis 
covers  a  wide  range  of  clinical  cases,  and 
includes  in  its  symptomatology  an  al- 
most-endless combination  of  symptom- 
groups,  which  depend  for  their  associa- 
tion upon  the  nature,  grade,  extent,  and 
location  of  the  inflammation  within  the 
encephalon,  as  well  as  upon  many  con- 
comitant conditions  which  may  exist  in 
the  patient.  All  of  the  symptom-groups 
have,  however,  usually  some  common 
characteristics,  and,  while  accuracy  in 
diagnosis  is  probably  nowhere  else  more 
difficult,  in  many  of  the  cases  certain 
types  of  encephalitis  have  been  de- 
scribed which  show  considerable  uni- 
formity. In  the  consideration  of  the 
subject  it  seems  better  to  classify  the 
cases  upon  what  we  know  of  their 
pathology,  meagre  as  this  often  is,  than 
to  use  the  many  etiological  synonyms  so 
frequently  found  in  the  older  descrip- 
tions. In  the  present  state  of  our  knowl- 
edge certain  terms  commonly  used  are 
misleading  to  the  student.  This  applies 
to  the  terms  polioencephalitis  superior 
and  polioencephalitis  inferior,  introduced 
by  Wernicke,  and  also  to  the  polioen- 
cephalitis of  Striimpell.  These  terms  are 
widely  used  to  denote  some  well-known 
types  of  focal  encephalitis;  but,  since 
more  recently  many  cases  have  been  re- 
ported in  which  focal  encephalitis  in- 
volved both  the  gray  and  white  sub- 
stance, it  would  seem  that  such  syn- 
onyms as  proposed  by  Wernicke  and 
Striimpell  only  serve  to  confuse,  as  re- 
marked by  Mills  in  his  recent  excellent 
work  upon  diseases  of  the  nervous  sys- 
tem. Encephalitis  is  often  associated 
with  meningitis,  and  the  term  "mcnin- 
go-encephalitis"    is   applied    to    inflam- 


mation of  the  membranes  and  subjacent 
brain-cortex. 

Varieties.  —  For  convenience  of  de- 
scription encephalitis  may  be  classified 
as  follows: — 

I.  Acute    non-suppurative    encepha- 

litis, 
(a)  Focal. 
(6)  Diffuse, 
(c)  Disseminated. 

II.  Acute  suppurative  encephalitis, 
(a)  Focal     or    circumscribed     (ab- 
scess), single  or  multiple. 

(6)  Diffuse. 

III.  Chronic  encephalitis. 

(a)  Terminal  stages  of  cases  arising 
acutely,  but  resulting  in  chronic 
cerebral  lesions. 

(b)  Chronic  meningo-encephalitis. 

(c)  Chronic  softening  due  to  en- 
cephalitis. 

IV.  Prenatal  encephalitis. 

Acute  Non-suppiirative  Encephalitis. 

Acute  non-suppurative  encephalitis 
occurs  most  frequently  in  infancy  and 
childhood,  but  may  occur  at  any  age. 
Since  the  paper  of  Striimpell  in  1884 
much  interest  has  been  awakened  in  the 
whole  subject  of  cerebral  inflammation, 
and  a  considerable  number  of  cases  have 
been  reported  in  which  the  autopsies 
have  proved  beyond  doubt  the  existence 
of  acute  non-suppurative  encephalitis  as 
a  distinct,  primary  affection.  By  some 
authorities  it  is  held  that  acute  non- 
suppurative encephalitis  during  foetal 
and  infantile  life  is  the  prime  factor  in 
the  etiolog}'  of  a  considerable  propor- 
tion of  cases  of  chronic  degenerative  dis- 
eases of  the  brain,  including  infantile 
cerebral  paralysis,  disseminated  sclerosis, 
and  bulbar  paralysis.  Observations,  re- 
corded since  1884,  upon  cases  present- 
ing the  symptoms  of  acute  encephalitis, 
tend  to  confirm  this  view;  and  it  seems 
to  be  fairly  established  that  acute  en- 


676 


ENCEPHALITIS.    ACUTE  XON-SUPPURATIVE.    SYMPT0:US. 


cephalitis  quite  commonly  leaves  residual 
affections,  especially  motor  and  psychical 
in  character.  Certain  writers  have  af- 
firmed a  special  tendency  of  acute  non- 
suppurative encephalitis  to  attack  the 
motor  regions  of  the  brain;  but  this 
may  be  only  seemingly  so,  because  of  the 
great  difficulty  of  observing  defects  of 
the  special  senses  in  children.  While 
there  are,  undoubtedly,  certain  areas 
which,  when  they  present  an  acute  in- 
flammation, give  us  more  typical  signs 
of  its  presence  than  do  many  of  the  so- 
called  '-'silent  regions"  of  the  brain,  one 
cannot  review  the  post-mortem  records, 
meagre  as  they  still  are,  without  con- 
cluding that  acute  inflammation  attacks 
quite  impartially  the  gray  and  white 
matter,  the  cortex  and  basal  ganglia,  the 
lining  membrane  of  the  ventricles,  and 
the  enveloping  membranes  of  the  en- 
cephalon. 

Two  forms  of  acute  non-suppurative 
encephalitis  may  be  said  to  exist  clin- 
ically, according  to  the  extent  and  dis- 
tribution of  the  inflammatory  process. 

Acute  focal  nonsuppurative  encepha- 
litis means  a  more  or  less  circumscribed 
area  in  one  lobe,  or  a  number  of  inflam- 
matory foci  grouped  together  in  one  lobe 
or  region  of  the  brain. 

Acute  diffuse  nonsuppurative  encepha- 
litis may  affect  an  entire  lobe  or  hemi- 
sphere, or  both  hemispheres. 

Acute  disseminated  encephalitis  is  so 
rare  an  affection  that  no  clinical  type 
can  be  described. 

Symptoms. — The  symptoms  of  acute 
non-.suppiirative  encephalitis  vary  in 
their  character  according  to  the  extent 
and  intensity  of  the  process,  the  cause 
producing  the  inflammation,  and  the 
particular  region  affected.  In  certain 
cases,  however,  the  post-mortem  exami- 
tion  failed  to  reveal  lesions  commen- 
Burate  with   the  symptoms  during  life. 


and  the  conclusion  has  been  reached 
that,  especially  in  those  cases  of  acute 
non-suppurative  encephalitis  following 
influenza,  typhoid  fever,  and  the  acute 
infections  generally,  there  is  a  toxic  ele- 
ment which  not  only  intensifies  the 
symptoms  due  to  organic  lesions  also 
present,  but  is  capable  of  causing  a  fatal 
termination  in  cases  which  after  death 
may  show  compai-atively-slight  lesions. 
This  intensification  of  the  symptoms  due 
to  the  primary  toxEemia,  may  explain  the 
rapid  and  complete  recoveries  which  at 
times  occur  in  the  paralytic  phenomena 
in  such  cases.  Few  cases,  however,  pass 
through  an  attack  of  acute  encephalitis 
without  some  lasting  mental  or  physical 
defect.  The  symptoms  of  acute  non- 
suppurative encephalitis  will  be  de- 
scribed according  as  the  disease  is  focal 
or  diffuse,  although  they  have  many 
symptoms  in  common. 

(a)  Acute  focal  non-suppurative  en- 
cephalitis occurs  most  frequently  in 
children,  but  cases  are  reported  in  adults, 
especially  after  influenza,  and  in  alco- 
holics. The  onset  is  usually  sudden: 
after  or  during  an  attack  of  some  acute 
infectious  disease  of  childhood,  or  after 
influenza,  diphtheria,  typhoid  fever,  or, 
more  rarely,  after  traumatism;  there 
are  headache,  vomiting,  fever,  convul- 
sions (single  or  repeated),  irritability, 
and  restlessness,  with  a  tendency  toward 
hebetude,  or  stupor.  There  may  be  an 
initial  chill,  or  repeated  chilly  sensations 
may  be  complained  of  by  the  patient. 
When  the  disease  arises  during  the 
course  of  some  acute  infectious  disease 
the  significance  of  the  symptoms  may  be 
easily  overlooked,  or  attributed  to  men- 
ingitis, until  some  form  of  paralysis 
makes  the  nature  of  the  case  clearer. 
The  typical  case,  however,  runs  a  more 
or  less  irregular  course.  Drowsiness  is 
usually  an  early  and  a  very  characteristic- 


ENCEPHALITIS.    ACUTE  XON-SUPPUKATIVE.    SYMPTOMS. 


6?7 


symptom,  and  this  encephalonarcosis 
may  persistently  deepen,  especially  in 
rapidly-fatal  eases,  or  it  may  alternate 
with  periods  of  restlessness  and  delirium. 
In  nearly  all  cases  mental  obtuseness  is 
present,  and  in  some  cases  there  is  also 
marked  confusion  of  ideas,  which  may 
persist  after  the  acute  symptoms  have 
passed  away.  The  convulsions  may  be 
toxic  or  chronic,  local  or  general,  and 
are  not  characteristic  of  anything,  dur- 
ing the  acute  stage,  except  as  denoting 
a  cerebral  irritation.  Eigidity  of  the 
spinal  muscles  and  opisthotonos  may 
occur,  but  the  latter  is  much  less  fre- 
quent than  in  meningitis.  The  fever 
runs  a  moderate  course,  rarely  exceed- 
ing 103°  F.  and  subnormal  variations 
are  not  uncommon,  especially  during  the 
comatose  states,  which  generally  super- 
vene rapidly  after  the  acute  onset.  Dur- 
ing the  acute  progress  of  the  disease 
some  form  of  paralj'sis  may  be  noticed, 
or  it  may  be  almost  the  first  sign  in 
certain  cases  (see  case  reported  by  Put- 
nam in  the  Journal  of  Nervous  and 
Mental  Diseases,  '97),  which  begin  usu- 
ally less  acutely  than  these  cases  oc- 
curring in  connection  with  the  acute 
infectious  diseases.  In  other  cases  oc- 
curring during  the  height  of  an  acute 
infectious  disease,  the  paralysis  may 
remain  unnoticed  until  convalescence  is 
well  established,  and  the  diagnosis  of 
the  case  thus  disclosed.  The  paralysis 
may  take  any  form,  and  sensation  may 
be  affected,  although  few  observations  of 
this  kind  are  on  record.  The  paralysis 
may  or  may  not  be  attended  by  spasm 
of  the  afTccted  muscles.  Atrophy  is  usu- 
ally of  limited  degree  when  present  at 
all,  and  Spitzka  has  observed  hyper- 
trophy of  certain  paralyzed  muscle- 
groups.  The  location  of  the  inflamma- 
tion determines  the  form  of  the  resulting 
paralysis.    In  the  type  of  acute  encepha- 


litis described  by  Striimpell  in  1884, 
and  considered  by  him  as  strictly  anal- 
ogous to  infantile  poliomyelitis  and  the 
bulbar  type  of  polioencephalitis  de- 
scribed by  Wernicke,  it  has  since  been 
found  that  the  lesions  quite  commonly 
involve  the  white  substance  as  well  as 
the  cortex.  For  this  reason  the  writer 
concurs  with  Mills  that  the  term  "cor- 
tical encephalitis,"  while  true  of  certain 
cases,  is  not  as  good  as  focal  encepha- 
litis, which  can  include  all  of  these  acute 
intracerebral  inflammations,  whether 
cortical,  subcortical,  or  basal  in  location. 

The  sequelae  which  have  been  noted  in 
cases  of  focal  encephalitis  include  pa- 
ralysis, with  or  without  spastic  condi- 
tions; contractures,  atrophy,  epilepsy 
(often  Jacksonian),  hemichoreas,  hemi- 
athetosis,  peculiar  associated  movements, 
and  imbecilit)',  all  varying  in  degree  ac- 
cording to  the  location,  extent,  and  se- 
verity of  the  inflammation.  When  the 
process  is  confined  chiefly  to  the  cortex, 
the  resultant  paralysis  may  be  mono- 
plegic,  hemiplegic,  paraplegic,  or  di- 
plegic,  according  to  its  extent.  If  oph- 
thalmoplegia is  present,  which  is  some- 
times associated  with  some  degree  of 
facial  paralysis,  the  inflammation  is  usu- 
ally found  to  involve  the  gray  matter  of 
the  floor  of  the  fourth  ventricle,  the 
aqueduct  of  Sylvius,  and  adjacent  struct- 
ures. This  form  corresponds  to  the  polio- 
encephalitis superior  described  by  Wer- 
nicke, Thomson,  and  others. 

Another  form  also  described  by  Wer- 
nicke and  termed  by  him  "polioencepha- 
litis inferior"  has  lahio-glosso-lari/nrical 
parahjsis  as  the  chief  clinical  character- 
istic. In  some  cases  of  the  latter  form 
ophthalmoplegia  may  develop  during 
the  progress  of  the  disease.  The  lesion 
of  polioencephalitis  inferior  has  been 
found  in  the  motor  nuclei  of  the  post- 
oblongata  and  adjacent  nerve-roots. 


6T8 


EXCEPHALITIS.    ACUTE  XOX-SUPPL'KATIVE.    SITJPTOMS. 


Some  cases  of  acute  focal  encepha- 
litis may  begin  insidiously,  with  very 
slight  febrile  reaction  and  gradual  de- 
velopment of  paralytic  symptoms. 

Case  in  which — after  slight  fever — 
'"external  ophthalmoplegia,  cycloplegia, 
iridoplegia,  and  ptosis  with  diplegia 
facialis''  and  muscular  inco-ordination 
developed  within  a  period  of  two  weeks, 
and  after  a  course  of  ten  days  resulted 
in  progressive  aud  perfect  recovery. 
Wolfe  (Jour,  of  Nerv.  and  Mental  Sci., 
•94). 

Case  of  a  man  in  whom  indistinctness 
of  speech,  followed  by  weakness  of  the 
movements  of  the  lips,  and  difficulty  in 
mastication  were  the  first  symptoms. 
There  was  then  ptosis,  diplopia;  the 
knee-jerks  were  slightly  increased;  the 
eyes,  aside  from  the  paresis  of  the  muscle, 
normal.  Strychnine  was  steadily  em- 
ployed, with  considerable  improvement 
in  the  symptoms.  The  diagnosis  was 
made  of  poliencephalitis  involving  the 
motor  nuclei  of  the  pons  and  medulla, 
the  bilateral  character  of  the  symptoms 
being  the  most  important  indication  of 
central  origin.  Walton  (Boston  Med. 
and  Surg.  Jour.,  Feb.  1,  1900). 

This  type  of  case  is  far  more  frequent 
in  adults  than  in  children,  and  corre- 
sponds exactly  to  the  description  by 
AA'ernicke  of  polioencephalitis  superior 
acuta,  with  the  exception  that  recovery 
ensued.  Interesting  cases  of  analogous 
symptomatology  have  been  reported  by 
Putnam  and  others,  but  our  knowledge 
of  the  affection  is  mainly  from  the 
studies  of  German  observers,  including 
Striimpell,  Wernicke,  Oppenhein  ,  Nau- 
werck.  Brie,  Freyhan,  ard  others. 

Very  instructive  case  in  a  woman  of 
30,  who  exhibited  loss  of  appetite,  ab- 
dominal pain,  slight  fever,  hebetude, 
rigidity  of  ncckmusoles,  dilatation  of 
one  pupil,  coma,  and  death,  with  in- 
creased temperature.  The  post-mortem 
examination  revealed  numerous  foci  of 
hemorrhagic  softening  throughout  the 
substance  of  both  cerebral  hemispheres. 
Brie  (Allg.  /eit.  f.  Psych.,  B.  53,  p. 
fi04). 


Case  of  poliencephalitis  in  an  adult  in 
which  a  study  of  the  clinical  symptoms 
and  the  autopsical  findings  led  to  the 
following  conclusions:  (1)  Landry's 
paralysis  may  be  due  to  poliomyelitis; 
(2)  the  latter  is  an  infectious  disease,  the 
inflammation  being  greatest  in  the  an- 
terior horns,  but  occurring  also  in  the 
posterior  horns,  the  white  matter,  and 
the  meninges;  (3)  the  symptoms  are 
motor  in  type,  because  the  disease  is  es- 
pecially of  the  anterior  horns;  (4) 
meningitis  is  not  uncommon  in  polio- 
myelitis; (5)  poliomyelitis  in  the  adult 
is  essentially  the  same  disease  as  polio- 
myelitis in  the  child;  (G)  it  is  related 
pathologically  to  the  non-purulent  form 
of  encephalitis  and  to  the  polienceph- 
alitis of  Wernicke.  De  Witt  H.  Sherman 
(Phila.  Med.  Jour.,  Mar.  31,  1900). 
This  type  is  frequent  among  the  re- 
ported cases. 

[Nauwerck  has  reported  several  cases, 
one  of  which  illustrates  how  rapidly  fatal 
the  disease  may  be.    The  patient  in  this 
case  was  a  girl  of  19,  who  presented  the 
following  symptoms:    Headache,  an  un- 
steady   or    staggering    gait,    faintness, 
vomiting,   loss   of  pupillary   light-reflex, 
slow  pulse,  fever,  hebetude  with  restless- 
ness, and  death  on  the  following  day. 
The  autopsy  revealed  a  focal  encephalitis, 
surrounded  by  a  zone  of  acute  softening, 
and  a  bacillus  identical  with  the  bacillus 
of  induenza  was  found  in  the  lesion  and 
also    in    the    ventricular    fluid.      C.    M. 
Hav.] 
The     symptom-group     described     by 
Striimpell    differs    from    the   Wernicke 
form  of  focal  encephalitis  in  that  paral- 
ysis of  the  external  eye-muscles  is  pres- 
ent in  the  latter  as  a  prominent  symp- 
tom,   and    optic    neuritis    is   far   more 
commonly  present.     The  other  general 
motor  disturbances,  with  impairment  of 
speech,   may   bo   identical   in   the   two 
forms.     When  ocular-nerve  palsy  is  as- 
sociated   with    polioencephalitis, — cases 
of  which  have  been  reported  by  Rothen- 
thal,  Sceligmiiller,  Guinon,  Sachs,  and 
others, — the  afPoction  is  termed  polio- 
encephalomyelitis.    It  is  extremely  rare, 


ENCEPHALITIS.    ACUTE  NON-SUPPURATIVE.    SYMPTOMS. 


679 


does  not  occur  in  childhood,  and  runs  a 
more  or  less  subacute  course. 

These  differing  forms  of  acute  focal 
encephalitis  which  have  been  referred  to 
illustrate  the  chief  clinical  types  of  the 
disease.  The  most  common  of  them  is 
that  occurring  in  infancy  or  childhood, 
after  or  during  one  of  the  acute  in- 
fectious diseases.  The  next  type  in  fre- 
quency is  that  occurring  in  adult  life 
as  a  result  of  the  poison  of  influenza, 
chronic  alcoholism,  or  without  apparent 
cause.  The  least  frequent  is  the  type 
due  to  traumatism,  which  more  fre- 
quently causes  a  diffuse  inflammation. 

The  part  played  by  acute  focal  en- 
cephalitis in  the  etiology  of  the  cerebral 
palsies  of  children  is  a  question  of  much 
interest,  and  is  as  yet  wholly  undeter- 
mined. Osier  believes  that  certain  of  the 
cases  of  sclerosis  and  porencephalus  may 
be  due  to  infantile  meningo-encephalitis, 
and  thinks  that  the  views  advanced  by 
Striimpell  have  not  met  with  the  con- 
sideration which  they  deserve.  J.  Lewis 
Smith  suggests  that  certain  cases  of  in- 
fantile hemiplegia  are  due  to  cortical 
encephalitis  induced  by  the  toxin  of 
eerebro-spinal  fever.  Jacobi  favors  the 
view  that  some  cases  of  cerebral  palsy 
in  children,  disseminated  sclerosis,  and 
bulbar  paralysis  are  results  of  prenatal 
or  infantile  primary  inflammation  of  the 
brain.  The  exact  relationship,  however, 
between  acute  focal  encephalitis  in  early 
life  and  these  forms  of  paralysis  still 
awaits  further  pathological  evidence. 

It  will  be  noticed  that  the  symptoms 
of  acute  focal  encephalitis  are  practically 
of  the  same  character  in  the  adult  as 
they  are  in  the  child,  although  they  are 
often  less  marked  in  the  adult,  and  the 
residual  paralyses  and  other  affections 
above  referred  to  are  likely  to  be  less 
severe.  The  reason  for  these  differences 
in  degree  probably  lies  in  the  natural 


differences  which  exist  between  the  com- 
paratively poorly  developed  fcetal  and 
infantile  brain  as  compared  with  the 
matured  organ.  The  brain,  being  the 
last  organ  to  develop,  during  infantile 
life  is  softer  and  relatively  more  vas- 
cular, due  to  the  larger  proportion  of 
water  it  contains;  therefore  it  is  not 
surprising  that  acute  inflammation  is 
far  more  frequent  in  infancy  and  child- 
hood than  during  any  other  period  of 
life. 

(6)  Acute  diffuse  non-suppurative  en- 
cephalitis presents  symptoms  which  in 
the  acute  stage  closely  resemble  those 
attending  the  focal  variety.  They  will, 
of  course,  vary  with  the  location,  extent, 
and  severity  of  the  inflammatory  process. 
It  occurs  at  any  age  of  life,  but  the  cases 
are  more  numerous  below  the  age  of 
twenty,  according  to  the  statistics  of 
Knaggs  and  Brown.  This  form  of  cere- 
bral inflammation  may  be  rapidly  fatal, 
or  it  may  run  a  subacute  course,  finally 
ending  in  a  chronic  condition.  Com- 
plete recovery  is  exceedingly  rare,  but 
partial  recovery  is  not  uncommon.  It 
occurs  most  frequently  after  traumatism, 
as  the  exciting  cause.  The  cases  occur- 
ring in  adult  life  are  commonly  due  to 
alcohol,  syphilis,  or  traumatism.  Cases 
also  occur  in  which  it  is  impossible  to 
assign  a  definite  cause;  but  it  is  prob- 
able that,  as  infection  is  an  important 
cause  of  focal  encephalitis,  it  is  also  a 
more  or  less  frequent  cause  of  the  dif- 
fuse form  of  the  disease.  Although 
there  is  little  regiilarity  in  the  appear- 
ance of  its  symptoms,  the  onset  of  acute 
diffuse  non-suppuritive  encephalitis  is 
apt  to  be  marked  by  dull  or  boring  pain 
in  the  head,  fever  with  delirium  or 
stupor,  local  or  wide-spread  muscular 
spasm,  and  some  form  of  paresis  rapidly 
increasing  to  paralysis,  usually  spastic 
in  character.     Mental  hebetude,  or  tor- 


680 


ENCEPHALITIS.    ACUTE  KON-SUPPUEATIVE.    ETIOLOGY. 


por,  appears  early,  and  throughout  the 
disease  is  a  ver)-  marked  feature.  The 
reflexes  are  increased  in  the  paralyzed 
parts.  Sensation  is  affected  according  to 
the  seat  of  the  lesion.  The  temperature 
may  be  subnormal  on  the  paralyzed  side 
in  hemiplegic  cases.  Optic  neuritis, 
which  may  be  present,  is  not  so  frequent 
as  in  suppurative  meningitis  or  encepha- 
litis. Localized  muscular  tremblings 
frequentl}'  occur  early,  and  may  be  the 
first  s}'mptom.  These  spastic  movements 
may  affect  any  portion  of  the  body,  but 
more  frequently  one  arm  or  the  muscles 
of  the  face  and  neck.  Cases  are  reported 
in  which  there  has  been  incessant  spasm 
of  the  facial  muscles,  the  tongue,  the 
ocular  muscles,  and  the  muscles  of  mas- 
tication. With  these  spastic  features 
general  convulsions  may  occur,  which 
may  be  repeated.  The  pupils  are  con- 
tracted or  unequal.  If  the  patient  sur- 
vives the  acute  stage,  apathy  and  stupor 
become  more  marked.  On  arousing  the 
patient  great  mental  degeneration  is  ap- 
parent. The  evacuations  are  voluntary. 
The  temperature  falls  and  a  subnormal 
range  is  common.  The  disease  runs  a 
course  of  from  a  few  hours  to  five  or  six 
weeks.  Most  cases  run  several  weeks. 
Some  cases  partially  recover  and  con- 
tinue to  live  with  chronic  conditions  of 
paralysis  and  mental  disease.  Certain 
cases  of  acute  delirious  mania  exhibit 
post-mortem  the  lesions  of  an  acute  dif- 
fuse non-suppurative  encephalitis. 

(c)  Acute  disseminated  non-suppura- 
tive enceplialitis  lia.'?  no  distinct  clinical 
existence.  It  may  occur  as  a  result  of 
syphilis,  or  during  ^,he  course  of  the 
acute  infectious  diseases,  as  typhoid  and 
typhus  fever,  erysipelas,  scarlet  fever, 
diphtheria,  small-pox,  influenza,  septi- 
CfT'mia,  and  pya?mia.  Patliologically, 
small  foci  of  inflammation  appear  quite 
early  distriljuted  tlirougliout  the  brain. 


Colonies  of  micrococci  have  been  found 
scattered  throughout  the  brain.  This 
condition  has  been  termed  mycosis  of 
the  brain.  The  symptoms  produced  by 
these  lesions  must  vary  indefinitely  with 
their  number  and  distribution.  The 
cases  reported  are  too  few  to  base  any 
clinical  description  upon. 

Although  acute  non-suppurative  en- 
cephalitis has  been  established  as  a  clin- 
ical type  by  the  studies  of  many  well- 
qualified  observers,  its  etiology  is  still 
largely  a  matter  of  speculation.  It  is 
true  that  we  know  something  of  the  con- 
ditions favorable  to  its  development,  but 
why  the  affections  which  give  rise  to  it 
at  times  are  not  more  frequently  fol- 
lowed by  this  disease,  when  it  is  consid- 
ered that  they  are  very  common  dis- 
eases, is  hard  to  explain.  It  can  be 
stated  that  at  present  we  are  almost 
wholly  ignorant  of  its  primary  causative 
factor,  and  the  exact  mode  of  produc- 
tion of  the  inflammatory  lesions. 

Etiology. — Acute  non-suppurative  en- 
cephalitis in  its  focal  manifestations 
most  frequently  occurs  in  connection 
with  some  acute  infectious  disease.  It 
may  arise  during  the  progress  of  the 
infective  process,  or  days  or  weeks  after 
convalescence  has  been  established.  The 
diseases  with  which  it  has  most  fre- 
quently been  associated  are  influenza,  the 
acute  infectious  diseases  of  cliildliood, 
typhoid  fever,  and  diphtheria.  Certain 
cases  occur  in  which  these  infections  are 
absent.  This  fact  has  been  explained 
by  some  writers  upon  the  subject  as 
pointing  to  the  probable  existence  of  a 
definite  toxin  peculiar  to  the  disease. 
Leichtenstcrn  and  Nauwcrck  believe  that 
the  focal-ha!morrhagic  form  of  acute  en- 
cephalitis may  l)e  of  bacterial  emljolic 
origin.  The  latter  observer,  with  Pfuhl 
and  many  others,  think  tliat  the  nervous 
.symptoms  may  l)e  tlic  first  sign  of  tlie  in- 


ENCEPHALITIS.    ACUTE  NON-SUPPUaATI\E.    PATHOLOGY. 


681 


fection.  Traumatism  may  be  a  cause  of 
both  focal  and  diffuse  encephalitis,  but 
is  far  more  frequently  causative  of  the 
latter.  The  same  may  be  said  of  alcohol 
and  syphilis. 

Acute  non-suppurative  encephalitis  of 
all  varieties  is  far  more  frequent  under 
the  twentieth  year  of  life,  and  the  ma- 
jority of  cases  of  acute  focal  encepha- 
litis occur  during  infancy  and  childhood. 
After  the  age  of  twenty  alcohol,  syph- 
ilis, traumatism,  and  the  influenza  in- 
fection are  the  chief  causes  recorded.  It 
has  also  been  known  to  follow  sun-stroke. 

Pathology. — The  few  autopsies  which 
have  been  made  in  cases  of  acute  non- 
suppurative encephalitis  show  in  the 
acute  focal  lesions  the  presence  of  the 
ordinary  appearances  of  acute  infiani- 
niation  of  brain-tissue,  and  very  com- 
monly associated  with  numerous  punc- 
tate hemorrhages  within  the  affected 
areas.  The  patches  may  be  small,  sin- 
gle or  multiple,  and  either  confined  to 
a  small  portion  of  one  lobe  or  more  or 
less  diffused  throughout  one  region  of 
the  brain.  Macroscopically  the  acute  le- 
sions are  reddish  gray  in  color,  of  dimin- 
ished consistence,  sometimes  amounting 
to  acute  red  softening,  and  are  sur- 
rounded usually  by  an  area  of  increased 
vascularity,  showing  lesser  degrees  of  the 
inflammatory  process  until  normal  brain- 
tissue  is  reached.  In  some  cases  the 
process  is  sharply  defined,  but  no  dis- 
tinct limiting  membrane  has  been  de- 
scribed. The  htemorrhages,  which  are 
common  in  these  cases,  are  usually  small 
and  punctate  in  form,  hut  may  be  large 
and  attended  by  disintegration  of  the 
brain-tissue  in  their  immediate  neigh- 
borhood. Microscopically  these  lesions 
present  the  evidences  of  an  e.xudative 
inflammation.  The  vessels  are  seen  to 
be  ruptured  here  and  there,  an  exodus 
of  leucocytes  is  seen  especially  marked 


about  the  vessels  and  often  distending 
the  perivascular  lymph-spaces,  while 
granular  cells  are  apt  to  be  present. 

Upon    iiiicroscopical    examination    in 
acute  cases  of  this  kind,  aggregations  of 
large  round  or  angular  epithelioid  cells 
constantly  found;   these  cells  exhibit  a 
great  tendency   toward   fatty   degenera- 
tion.    Friedniann    (Keurologisches   Cen- 
tralblatt,  Aug.  1,  '00). 
The     parenchymatous     changes     are 
probably  secondary  to  the  vascular  le- 
sions, and  broken-down  cells  and  disin- 
tegrated nerve-fibres  are  seen  when  the 
inflammatory  process  has  progressed  far 
enough  to  destroy  these  elements.    The 
role  of  the  infecting  microbes  in  the 
cases  arising  from  infectious  diseases  is 
still  a  question.     Whether  they  operate 
directly  from  the  blood  upon  the  tissues 
or  whether  the  lesions  are  due  to  some 
toxin    generated   by   them   is   undeter- 
mined.    When  basal  structures  are  at- 
tacked, the  cranial-nerve  roots  have  been 
found   to  be  affected  by  inflammatory 
changes    resulting    in    degeneration    or 
softening.      The    membranes    are    fre- 
quently implicated  when  the  inflamma- 
tion is  cortical,  and  may  present  bright- 
reddish  patches  due  to  distended  vessels 
and  minute  hjemorrhages. 

The  post-mortem  appearances  of  the 
diffuse  form  of  acute  encephalitis  do  not 
differ  markedly  from  the  localized  form 
except  in  the  greater  extent  of  the  lesion. 
During  its  acute  stage  there  are  the 
same  macroscopical  appearances  and  the 
brain  is  softened.  In  some  cases,  in 
which  the  inflammatory  reaction  is  less 
severe  and  of  longer  duration,  the  brain 
undergoes  hardening,  which  may  involve 
a  lobe  or  an  entire  hemisphere.  In  these 
cases  of  diffuse  inflammation  implication 
of  the  membranes  is  not  uncommon. 
In  most  cases  of  diffuse  encephalitis 
some  degree  of  softening  is  the  rule, 
jricroscopically  during  the  acute  stage 


682 


EN'CEPHALITIS.    ACUTE  XOX-SUPPUKATIVE.    DIAGNOSIS. 


the  vessels  are  dilated,  capillary  hsmor- 
rhages  are  frequent,  and  the  brain-tis- 
sue is  infiltrated  -n-itli  leucocytes,  which 
also  distend  the  perivascular  lymphatic 
sheaths.  Compound  granular  cells  appear, 
■with  secondary  degenerative  changes 
in  the  nerve-cells  and  axis-cylinders, 
with  active  proliferation  of  the  neurog- 
lia. This  process  progresses  at  times 
until  the  nerve-elements  are  more  or  less 
completely  destroyed  in  the  affected 
area.  In  cases  where  hardening  takes 
place  both  gray  and  white  substances 
may  be  involved,  but  it  has  been  espe- 
cially marked  in  the  white  substance. 
Pathologically,  the  hardening  is  due  to 
increase  of  the  connective  tissue,  espe- 
cially the  vascular  connective  tissue.  In 
one  of  the  cases  collected  by  Knaggs 
and  Brown,  the  white  substance  of  both 
hemispheres  was  found  very  much  hard- 
ened, while  the  cortical  substance  was 
so  soft  as  to  be  easily  washed  off  by  a 
stream  of  running  water,  giving  the  ap- 
pearance afterward  of  a  plaster  cast  of 
the  encephalon. 

Diagnosis. — The  recognition  of  acute 
non-suppurative  encephalitis  during  the 
period  of  its  inception  must,  in  nearly 
all  cases,  be  attended  witli  difficulty. 
This  is  particularly  true  of  cases  occur- 
ring in  infancy  and  childhood,  where  it 
most  frequently  occurs  as  a  complication 
or  sequel  of  some  of  the  acute  infectious 
diseases.  Very  often  it  is  not  until  the 
development  of  some  form  of  paralysis 
that  the  disease  is  suspected  to  exist, 
and  only  the  most  careful  study  of  each 
individual  case  can  separate  this  affec- 
tion from  meningitis,  with  which  it  i.s, 
no  doul)t,  fre(|uent]y  associated.  This  is 
especially  apt  to  be  true  in  traumatic 
cases.  In  all  cases  in  which,  during  the 
progress  of  some  acute  general  disease 
cerebral  symptoms  arise,  in  which,  after 
a  period  marked  by  moderate  signs  of 


cerebral  irritability,  there  results  a  paral- 
ysis out  of  proportion  in  severity  with 
the  general  symptoms  which  might  be 
expected  to  be  present  in  meningitis, 
and,  if  other  obvious  exciting  causes  of 
the  latter  can  be  excluded,  the  presump- 
tion would  be  in  favor  of  encephalitis. 
'Uliile  no  rule  can  be  made  with  any 
degree  of  certainty,  it  is  probable  that 
premonitory  symptoms  are  far  more 
common  and  last  a  longer  period  in  men- 
ingitis before  stupor  and  coma  super- 
vene. Photophobia,  intolerance  of  light, 
and  retraction  of  the  head  are  often  per- 
sistent in  meningitis  for  daj^s  and  even 
weeks  before  the  stage  of  coma  is 
reached.  In  all  recorded  cases  of  acute 
non-suppurative  encephalitis  the  tend- 
ency to  dullness,  apathy,  stupor,  or  coma 
is  a  marked  and  often  early  feature. 
The  presence  of  optic  neuritis  favors 
meningitis,  while  its  absence  is  wholly 
without  diagnostic  significance. 

The  best  guide  to  a  correct  diagnosis, 
in  cases  where  this  is  possible,  between 
acute  focal  non-suppurative  encephalitis 
and  the  different  forms  of  meningitis 
is  a  careful  study,  not  of  any  particular 
symptom-group,  but  of  the  entire  case. 
There  is  no  absolutely  diagnostic  sign 
by  which  they  can  be  clinically  sepa- 
rated, but  a  careful  review  of  the  onset, 
course,  and  succession  of  the  symptoms 
will  afford  more  valuable  information 
than  will  any  study  of  particular  symp- 
toms. Thus  it  will  be  borne  in  mind 
that  both  affections  are  very  rare  com- 
plications of  tlie  acute  infectious  dis- 
eases, but  that  meningitis  is  tlie  more 
common;  that  any  local  source  of  septic 
infection,  rheumatism  with  endocarditis, 
adjacent  disease  of  the  cranial  bones, 
erysipelas,  and  septicjemia,  more  fre- 
frequently  cause  meningitis;  and  tliat 
after  traumatism  meningitis  usually  de- 
velops at  once  or  within  two  or  three 


ENCEPHALITIS.     ACUTE  NONSUPPURATIVE.     PROGNOSIS.     TREATMENT. 


683 


days,  but  the  signs  of  encephalitis  usu- 
ally do  not  appear  until  considerably 
later.  In  this  connection  it  may  be  men- 
tioned that  cases  of  acute  encephalitis, 
from  severe  concussion  iipon  the  op- 
posite side  from  the  point  of  reception 
of  the  injury,  have  been  reported. 

In  cases  running  a  subacute  course  the 
decided  mental  deterioration  with  long 
spells  of  extreme  torpor  or  even  semi- 
comatose states,  and  persistent  spastic 
paralysis,  have  been  the  salient  features 
of  certain  reported  cases  of  diffuse  non- 
suppurative encephalitis.  Cases  of  spas- 
tic hemiplegia  and  diplegia  in  children 
quite  frequently  will  give  a  history  of  an 
initial  illness  attended  by  convulsions, 
coma,  and  fever,  and  it  is  probable  that  a 
number  of  these  cases  arise  from  acute 
non-suppurative  encephalitis  during  in- 
fancy. The  same  may  be  said  of  certain 
cases  of  disseminated  sclerosis  and  bulbar 
paralysis.  The  trend  of  opinion  seems 
to  favor  inflammatory  lesions  as  causa- 
tive of  many  of  the  chronic  degenera- 
tive diseases  of  the  brain  met  with  in 
adult  life.  Further  pathological  proof 
is  needed  to  establish  the  diagnostic 
features  of  acute  inflammation  of  the 
brain  in  early  life.  In  all  cases  of  in- 
flammation of  the  brain  after  trauma- 
tism the  possibility  of  a  non-suppura- 
tive diffuse  encephalitis  should  be  borne 
in  mind.  The  diagnosis  of  the  dissemi- 
nated type  can  at  present  be  little  more 
than  conjectural. 

Prognosis.  —  Tlie  prognosis  of  any 
form  of  acute  non-suppurative  encepha- 
litis is  grave,  both  as  regards  life  and  the 
outlook  for  perfect  recovery.  In  all 
forms  many  cases  die  during  the  acute 
attack.  The  prognosis  of  acute  focal 
non-suppurative  encephalitis  depends,  in 
great  measure,  upon  the  severity  of  the 
acute  primary  infection  with  which  it 
is  most  frequently   associated,   and    of 


which  we  must  at  present  regard  it  as 
a  resultant.  Cases  of  perfect  recovery 
from  paralysis  following  this  form  of  en- 
cephalitis are  not  uncommon,  and  the 
paralysis  in  these  cases  generally  shows 
improvement  for  a  year  following  the 
attack.  After  influenza,  especially,  this 
tendency  to  recover  from  apparently 
grave  conditions  is  marked.  Very  few 
cases,  however,  recover  perfectly. 

The  prognosis  of  diffuse  non-suppura- 
tive encephalitis  in  its  acute  form  is 
very  grave,  both  as  regards  life  and  re- 
covery from  residual  lesions.  There  is 
almost  no  hope  of  complete  recovery  in 
any  case.  Cases  having  both  hemi- 
spheres involved  generally  die  within  a 
few  days.  The  majority  of  cases  which 
run  a  subacute  course  may  live  a  num- 
ber of  months,  or  with  crippled  intelli- 
gence and  paralyzed  bodies  live  for  years. 
In  general  terms,  cases  of  acute  non- 
suppurative encephalitis,  which  begin 
abruptly,  with  decided  fever,  a  rapidly- 
increasing  comatose  condition,  and  ex- 
tensive paralysis  are  apt  to  be  rapidly 
fatal;  and,  conversely,  cases  beginning 
rather  insidiously,  with  slow  develop- 
ment of  symptoms,  oiler  more  hope  of  re- 
covery. All  grades  of  acute  non-sup- 
purative encephalitis  are  subject  to  ir- 
regularity in  course  and  symptoms,  so 
recovery  sometimes  occurs  from  appar- 
ently hopeless  conditions;  therefore  an 
absolutely  fatal  prognosis  should  not  be 
given  in  any  case. 

Treatment. — The  treatment  of  acute 
non-suppurative  encephalitis  will  vary 
somewhat  according  to  the  age  of  the 
patient,  the  previous  state  of  health, 
and  the  existence  or  not  of  some  acute 
infectious  disease;  but  the  same  general 
principles  which  govern  the  treatment 
of  acute  simple  meningitis  apply  to  all 
of  these  cases;  absolute  rest  in  bed  in 
a  darkened  and  well-ventilated  room  is 


684 


EXCEPHALITIS.     ACUTE  SUPPURATIVE. 


necessary  in  all  cases.  The  head  and 
shoulders  should  he  elevated.  Absolute 
quiet  on  the  part  of  the  attendants^  and 
the  exclusion  of  any  source  of  mental 
irritation  or  excitement  should  be  rig- 
idly enforced.  As  soon  as  the  existence 
of  the  disease  is  suspected,  local  deple- 
tion, by  means  of  dry  or  wet  cups  or 
leeches,  applied  to  the  nape  of  the  neck 
or  behind  the  ears,  or  to  the  temples; 
or  general  depletion  by  venesection  in 
healthy  sthenic  adults  with  severe  onset, 
should  be  practiced,  followed  in  all  cases 
by  the  ice-bag  to  the  head.  A  fly  blister 
may  be  applied  to  the  occiput,  and  is 
better  than  larger  blisters  applied  ex- 
tensively over  the  head.  When  there 
is  much  hair  the  scalp  should  be  shaved 
to  admit  of  the  fullest  effects  of  dry 
cold.  When  vomiting  is  present  small 
pieces  of  ice  may  be  given  by  the  mouth 
with  sips  of  cinnamon-water  at  times, 
and  a  mustard  plaster  should  be  applied 
over  the  epigastrium;  or  a  turpentine 
stoop  may  be  used  over  the  whole  abdo- 
men occasionally  for  this,  and  for  its 
derivative  effect.  At  the  same  time 
small  and  frequently  repeated  doses  of 
mercury,  preferably  calomel,  should  be 
administered  by  the  mouth,  followed  by 
a  brisk  purgative,  and  succeeded  by  the 
continued  administration  of  smaller 
doses  of  mercury  at  longer  intervals.  In 
suitable  cases  aconite  or  veratrum  viride 
may  be  given  during  the  onset  until 
their  full  physiological  effect  is  secured, 
but  in  cases  in  children  already  weak- 
ened by  disease  they  should  be  cautiously 
employed. 

For  the  control  of  pain  some  form 
of  opium  is  necessary,  and  wliere  there 
is  active  delirium  and  marked  local  or 
general  tremblings  or  irregular  tremor, 
it  may  be  combined  with  chloral  and  the 
bromides.     The  continuous  application 


of  dry  cold  should  be  maintained  during 
the  acute  stage. 

The  diet  should  consist  of  milk  or 
other  light  nutritious  preparations  in 
small  quantities,  and  they  may  be  pre- 
digested  artificially  with  benefit.  No 
stimulants  should  be  given  unless  ur- 
gently demanded  by  the  condition  of  the 
pulse.  Cases  demanding  stimulation  in 
the  early  days  of  the  disease  may  be 
given  strychnine,  supplemented  by  small 
doses  of  alcohol  or  ammonia  in  some 
form.  The  essence  or  wine  of  pepsin  or 
champagne  are  acceptable  stimulants  to 
children,  and  are  better  borne  by  the 
stomach  than  whisky  or  brandy.  If  the 
patient  cannot  swallow,  nutritive  ene- 
mata  should  be  given. 

Should  the  patient  survive  the  attack, 
and  the  case  continue  in  subacute  forms, 
treatment  must  be  directed  to  nourish- 
ing the  patient,  to  improvement  of  the 
general  condition,  and  toward  increasing 
muscular  power  in  paralyzed  parts. 
These  indications  are  to  be  met  by  care- 
ful and  systematic  feeding  of  light  and 
easily-digestible  articles,  by  massage, 
faradization,  and  Swedish  movements  of 
affected  members  to  prevent  contrac- 
tions. 

Acute  Suppurative  Encephalitis. 

Acute  inflammation  of  the  brain 
terminating  in  the  formation  of  pus  may 
be  a  focal  or  circumscribed  process,  in 
which  single  or  multiple  areas  are  af- 
fected; or  it  may  be  a  diffuse  process 
affecting  large  areas  of  the  cortex,  often 
with  implication  of  the  adjacent  mem- 
branes, or  larger  or  smaller  areas  of  the 
brain-substance  may  he  involved,  often 
including  the  lining  membrane  of  the 
ventricles.  The  majority  of  cases  of 
abscess  of  the  brain  are  inflammatory 
in  origin,  so  that  acute  suppurative  en- 
cephalitis in  its  circumscril)cd  or  focal 
form    is    practically    synonymous    with 


ENCEPHALITIS.    ACUTE  DIFFUSE  SUPPURAT1\"E. 


685 


cerebral  or  encephalic  abscess.  Certain 
cases  of  abscess  may  occur  witliout  any 
evidence  of  an  inflammatory  genesis. 
They  are,  however,  due  to  necrotic  soft- 
ening and  do  not  come  under  considera- 
tion here,  as  they  are  considered  under 
Cehebkal  Abscess.  Practically,  in- 
flammation of  the  brain,  in  its  suppura- 
tive form,  occurs  as  a  focal  or  diffuse 
disease,  and  the  former  is  clinically  ab- 
scess of  the  brain,  while  the  latter  is 
most  common  as  a  difEuse  meningo-en- 
cephalitis.  These  affections,  although 
closely  allied,  for  clearness  of  descrip- 
tion will  be  considered  separately. 

(A)  Acute  Focal  Suppurative  En- 
cephalitis. 

Synonyms. — Abscess  of  the  brain;  en- 
cephalic abscess.  (See  Cerebral  Ab- 
scess. 

(B)  Acute  Diffuse  Suppurative  En- 
cephalitis. 

Definition. — Dilfuse  suppurative  en- 
cephalitis, as  the  term  implies,  is  a  dif- 
fuse infective  inflammation  involving 
large  areas  of  the  brain,  often  with  coin- 
cident involvement  of  its  membranes, 
and  resulting  in  pus-formation. 

Symptoms. — The  symptoms  of  this  con- 
dition are  those  of  cerebral  irritation  and 
compression  of  large  and  in-egular  areas 
of  the  brain.  The  signs  present  point  to 
a  septic  process.  The  pulse,  tempera- 
ture, and  respiration  are  irregularly  af- 
fected; sudden  variations  in  all  three 
frequently  occur.  Chills  or  rigors  may 
be  a  marked  feature.  The  symptoms  in 
addition  which  are  present  in  whole  or 
in  part  in  such  cases  are  dull  and  deep 
pain  in  the  head,  stupor  with  attacks 
of  delirium,  irregular  local  or  general 
convulsions  or  paralysis,  optic  neuritis, 
various  forms  of  aphasia,  anaesthesias  or 
parresthcsias  of  irregular  distribution, 
oculomotor  palsy,  various  disorders  of 
\'ision,  or  of  other  special  senses,  accord- 


ing to  the  region  of  brain  involved.  The 
patient  may  die  within  a  few  days  or  a 
week,  especially  in  cases  due  to  severe 
head-wounds,  fractures,  or  lacerations  of 
the  brain-substance.  In  such  cases  an 
extensive  leptomeningitis  is  commonly 
present  in  addition.  In  other  cases  the 
acute  symptoms  pass  away  and  leave  the 
patient  in  a  condition  of  great  torpidity, 
with  pain  in  the  head,  spastic  or  chronic 
paralytic  phenomena,  occasional  con- 
vulsions and  progressive  loss  of  function 
in  those  parts  supplied  by  the  affected 
part  of  the  brain.  In  some  cases  patients 
may  linger  for  months  with  hopeless 
mental  deterioration,  extensive  motor 
and  sensory  paralysis,  and  partial  or 
complete  destruction  of  some  of  the  spe- 
cial senses.  Death  in  these  cases  finally 
results  from  exhaustion. 

Etiology. — This  form  of  suppurative 
enceplialitis  follows,  at  times,  severe  in- 
juries, or  it  may  be  a  complication  or  a 
sequence  of  one  of  the  acute  infectious 
diseases.  It  has  the  same  general  eti- 
ology as  the  focal  form  of  suppurative 
encephalitis,  already  referred  to.  It  is 
never  primary. 

Pathology.  —  Post-mortem  examina- 
tion reveals  large  areas  of  disorganized, 
pulpy,  soft,  or  even  semifluid  consistence 
of  the  affected  portion  of  the  brain.  The 
adjacent  membranes  are  likely  to  be  in- 
volved, and  may  be  softened,  deeply  con- 
gested, and  covered  ^-ith  purulent  exu- 
date, which  may  also  fill  up  the  sulci 
and  large  fissures  of  the  organ.  In  cases 
running  a  subacute  course,  the  mem- 
brane may  be  considerably  thickened, 
with  breaking  down  of  their  cerebral 
surfaces.  Microscopically  there  is  the 
pus-cell,  massing  of  leucocytes  around 
the  borders  of  the  process,  dilated  ves- 
sels and  perivascular  spaces,  and  within 
the  area  of  utter  destruction  are  seen 
compound  granule-cells,  granular  debris. 


686 


E^■CEPHALITIS.    CHROXIC. 


and  the  remnants  of  nerve-cells  and 
fibres.  Any  of  the  pathogenic  bacteria 
mentioned  under  acute  focal  suppura- 
tive encephalitis  may  be  present.  The 
bacillus  communis  coli  has  also  been 
observed  by  Howard. 

The  infection  followed  a  suppurating 
rectal  wound,  the  child  pcesenting  very 
interesting  congenital  malformations  of 
the  heart,  with  imperforate  rectum.  The 
post-mortem  lesions  in  this  case  were 
acute  purulent  ependymitis  and  encepha- 
litis (the  ventricles  being  distended  with 
pus),  with  basic  and  cortical  meningitis. 
The  pus  was  creamy,  yellow  green  in 
color,  and  a  micrococcus  was  present  in 
it  as  well  as  the  bacillus  communis  coli. 
Howard  (Johns  Hopkins  Hosp.  Bull., 
vol.  iii,  p.  59,  '92). 

In  some  of  the  cases  running  a  chronic 
course  the  brain-destruction  may  be  very 
great,  and  an  entire  hemisphere  or  even 
more  of  the  brain  be  destroyed,  and 
present  at  the  autopsy  a  semifluid  and 
purulent  mass. 

Diagnosis. — The  diagnosis  is  made  by 
a  study  of  the  cause  producing  the  con- 
dition, the  ver}-  grave  nature  and  the 
decidedly  septic  character  of  the  cerebral 
and  general  symptoms,  the  irregularity 
of  its  course,  and  the  irregular  and  wide- 
spread impairment  of  motor,  sensory,  or 
special-sense  functions,  according  to  the 
region  affected.  When  in  conjunction 
with  purulent  meningitis,  the  condition 
affecting  the  brain-substance  can  only 
be  suspected  by  the  intensity  of  the 
symptoms  present,  and  their  mode  of 
onset,  the  grave  set  of  paralytic  symp- 
toms with  mental  confusion  or  deep 
stupor,  often  succeeding  the  most  acute 
manifestations  of  the  meningeal  inflam- 
mation. 

In  some  cases  in  which  post-mortem 
examination  reveals  a  large  region  of  the 
brain  converted  into  pus,  and  especially 
in  those  cases  where  the  clinical  history 
was  one  of  gradual  loss  of  motor  or  sen- 


sory functions,  with  loss  of  memory,  con- 
fusion of  mind,  without  any  period  of 
active  inflammatory  symptoms  being 
traceable,  the  condition  has  been  called 
"cold  abscess  of  the  brain."  It  is  more 
probable  that  such  cases  should  be  placed 
in  a  distinct  class  and  that  the  fact  be 
recognized,  as  pointed  out  by  Gowers 
and  others,  that  there  is  this  form  of 
softening  which  depends  essentially 
upon  a  slow  chronic  form  of  encephalitis. 
These  cases,  however,  are  quite  rare,  and 
are  more  often  encountered,  probably  in 
hospitals  for  the  insane  than  in  civil 
practice.  It  is  apt  to  occur  in  advanced 
life,  at  least  after  the  age  of  forty. 

Prognosis. — The  disease  always  ter- 
minates fatally,  although  some  cases  last 
several  weeks. 

Treatment. — Little  need  be  said  of 
treatment,  which  must  usually  be  ex- 
pectant and  symptomatic.  Cases  pre- 
senting signs  of  superficial  pus-condi- 
tions should  have  the  benefit  of  trephin- 
ing. Trephining  with  drainage  of  the 
ventricles  may  also  be  practiced  in  cases 
where  the  ventricles  are  distended  Mith 
pus  and  signs  of  compression  are  great. 
Some  cases  of  this  kind  have  been  re- 
ported, in  which  free  collections  of  pus 
in  the  cerebral  fissures  have  been  evacu- 
ated and  drained  with  success,  so  that  in 
all  cases  in  which  a  diagnosis  can  be 
made  the  operation  should  be  performed. 

Chronic  Encephalitis. 

The  term  "chronic  encephalitis"  has 
an  indefinite  and  vague  meaning,  be- 
cause it  has  been  applied  by  different 
writers  to  a  number  of  pathological 
states.  As  a  clinical  type,  rare  cases 
exist  which  present,  post-mortem,  a  dif- 
fused general  sclerosis  of  evident  inflam- 
matory causation.  These  cases  are  rare, 
and  the  symptoms  observed  during  life 
are  very  variable  and  their  significance 
is   rarely   apparent   during  life.     Sole- 


ENCEPHALITIS.     CHRONIC.    DEFINITION.     VARIETIES. 


G87 


rosis  is,  according  to  some  authorities, 
always  primarily  an  inflammatory  proc- 
ess. If  this  be  assumed,  then  the  pa- 
thology of  almost  all  chronic  brain  dis- 
eases wovdd  have  chronic  encephalitis  as 
their  prime  causative  factor.  Consider- 
able doubt,  however,  exists  as  to  the 
essential  nature  of  ordinary  cerebral 
sclerosis,  and  positive  proof  is  lacking. 
In  gouty  patients,  according  to  Gowers, 
a  chronic  focal  inllammation  of  the  cor- 
tex may  exist  and  simulate  brain-tumor, 
and  optic  neuritis  may  be  present  in 
addition  to  focal  symptoms.  Ilughlings- 
Jackson  and  others  also  have  reported 
cases  of  seemingly  primary  chronic  en- 
cephalitis; but  the  cases  are  too  few  to 
need  a  separate  classification.  In  some 
of  these  cases  hypertrophy  of  the  cortex 
has  been  noticed. 

Definition. — In  the  present  state  of 
our  knowledge,  chronic  encephalitis  may 
be  defined  as  a  term  which  is  used  to 
denote  several  pathological  states,  but  is 
applied  more  especially  to  cases  in  which 
there  is  great  increase  in  the  connective- 
tissue  elements,  resulting  usually  in 
hardening  of  the  brain,  ^Tth  secondary 
degenerative,  nutritic,  and  functional 
changes  in  the  nerve-elements,  and  may 
rarely  produce  a  state  of  chronic  soften- 
ing. 

Varieties. — The  following  types  may 
be  said  to  show  greater  or  less  degrees  of 
chronic  encephalitis. 

(a)  Terminal  stages  of  cases  arising 
more  or  less  acutely,  but  resulting  in 
chronic  cerebral  lesions. 

In  this  class  may  be  included  those 
cases  presenting  residual  symptoms,  le- 
sions of  focal  and  diffuse  non-suppura- 
tive  encephalitis,  the  zones  of  dense  con- 
nective tissue,  proliferation  surround- 
ing old  cases  of  embolism, thrombosis,  ab- 
scess and  tumor,  the  secondary  reactive 
sclerosis  found  in  cases  of  spastic  paral- 


ysis, and  the  sclerotic  patches  of  dis- 
seminated sclerosis,  insular  sclerosis,  and 
the  syphilitic  forms  of  the  same  affect- 
ing the  brain  often  in  conjunction  with 
a  similar  spinal  lesion.  All  of  these 
pathological  states  are  essentially  of  the 
nature  of  a  chronic  inflammation,  and 
in  all  of  them  the  vascular  connective- 
tissue  element  predominates,  to  the  im- 
pairment or  destruction  of  the  parenchy- 
matous brain-tissue.  The  symptoma- 
tology of  all  of  the  above  lesions,  of 
course,  difl'er  widely  according  to  the 
site  of  the  lesions,  but  the  chronic  en- 
cephalitis undoubtedly  is  a  factor  in 
these  and  many  more,  which  readily  sug- 
gest themselves  to  the  mind  of  the 
student  of  nervous  diseases,  in  which  the 
sole  persistent  lesion  is  a  sclerosis  which 
is  of  undoubted  inflammatory  origin. 

(6)  Chronic  meningo- encephalitis. 
This  is  the  distinctive  lesion  of  paralytic 
dementia,  and  for  our  knowledge  of  its 
minute  anatomy  we  are  chiefly  indebted 
to  the  studies  of  Bevan  Lewis.  The 
brain-cortex  and  the  pia  mater  are  in- 
volved in  the  process.  It  may  also  effect 
the  brain  to  a  considerable  depth, 
varying  in  different  convolutions,  and 
ependymitis  is  frequently  also  present. 
Eaymond  considers  the  starting-point  of 
the  disease  in  sj'philitic  subjects  to  be  in 
the  walls  of  the  capillary  blood-vessels 
of  the  cortex.  Bevan  Lewis  recognizes 
three  stages  to  chronic  meningo-encepha- 
litis,  which  he  gives  as  follows:  1.  Stage 
of  inflammatory  proliferation  in  the 
tunica  adventitia  of  the  arterioles,  ^\-ith 
special  nuclear  proliferation,  alterations 
in  the  calibre  of  the  vessels,  and  sec- 
ondary trophic  changes  in  the  surround- 
ing tissue.  2.  Stage  of  development  of 
the  lymph-connective  system,  with  de- 
generation and  loss  of  nerve-cells  and 
fibres.  3.  Stage  of  fibrillation  of  con- 
nective-tissue   elements,    together   with 


688 


ENXEPHALITIS.    CHKOXIC.     SYilPTOMS. 


great  atrophy  of  the  affected  portion  of 
the  brain. 

On  removing  the  calvarium,  in  these 
cases,  it  is  noticed  that  the  dura  is  gen- 
erally more  or  less  adherent,  the  cerebro- 
spinal fluid  is  increased,  the  meshes  of 
the  pia  mater  are  oedematous  and  fill  up 
the  solei  all  over  the  cortex,  especially 
in  the  motor  area  and  over  the  postero- 
parietal  region.  The  cortex  and  mem- 
branes are  adherent;  so  that  often  the 
cortex  is  lacerated  on  removal  of  the 
membranes.  Marked  atrophy  of  the  con- 
volutions is  nearly  a  constant  feature. 
The  cortex  is  harder  than  normal.  On 
section  the  thickness  of  the  cortex  is 
diminished,  and  in  places  no  clear  de- 
markation  exists  between  the  gray  and 
white  matter.  There  is  ventricular 
dilatation  and  granular  ependymitis.  All 
of  these  changes  are  especially  marked 
over  the  frontal  and  parietal  regions. 

Pathological  findings  analogous  to  the 
above  are  also  observed  in  some  cases  of 
chronic  epilepsy,  and  in  certain  types 
of  chronic  dementia;  but  this  patho- 
logical combination  is  so  uniform  and 
striking  in  paralytic  dementia  that  it  has 
been  accepted  unanimously  as  the  lesion 
of  that  disease,  and  by  some  writers,  in- 
cluding Osier,  the  term  "chronic  men- 
ingo-encephalitis"  is  used  as  synonymous 
with  "general  paralysis  of  the  insane." 

The  symptoms,  etiology,  diagnosis, 
prognosis,  and  treatment  of  this  condi- 
tion need  not  be  referred  to  here,  since 
they  will  be  found  in  the  description  of 
paralytic  dementia,  which  is  here  only 
taken  as  the  most  prominent  type  of 
chronic  mcningo-encephalitis,  but  not  as 
the  sole  condition  in  which  this  lesion 
exists. 

(c)  The  consideration  of  forms  of 
chronic  softening  due  to  chronic  en- 
cephalitis need  scarcely  be  mentioned, 
since   the   evidence   upon    which    their 


pathology  rests  is  too  meagre.  The  ex- 
istence of  such  cases  has,  however,  been 
mentioned  by  Gowers  and  others,  but 
the  writer  has  been  unable  to  find  the 
accounts  of  any  post-mortem  examina- 
tions bearing  upon  the  subject.  The 
chronic  state  of  diifuse  or  focal  suppura- 
tion has  been  referred  to  as  a  sequel  to 
an  acute  inflammation. 

Symptoms. — The  symptoms  of  chronic 
encephalitis  will  depend  upon  its  vari- 
ety, etiology,  location,  and  the  grade  of 
the  process,  as  will  readily  be  appreciated 
when  the  wide  range  of  clinical  cases  in 
which  this  lesion  exists  is  considered. 
Reference  has  been  made  to  the  types 
described  by  Hughlings-Jackson  and  by 
Gowers,  in  which  more  or  less  severe 
signs  of  cerebral  irritation  existed  for 
months,  with  slight  fever,  and  sometimes 
spastic  neuritis,  especially  in  those  cases 
having  head-pain,  vomiting,  and  focal 
signs  simulating  those  of  tumor. 

In  all  cases  in  which  chronic  encepha- 
litis exists  as  a  complicating  or  reactive 
inflammatory  condition,  its  symptoma- 
tology is  essentially  that  of  the  primary 
condition  giving  rise  to  it.  This  refers 
to  cases  of  brain-tumor,  abscess,  em- 
bolism, thrombosis,  foreign  bodies  im- 
planted in  tlie  brain,  exostoses  of  tlie 
cranial  bones  inflicting  pressure  upon  the 
brain,  or  calcareous  growths  developed 
within  the  cerebral  membranes.  Chronic 
encephalitis  enters  also  into  the  pathol- 
ogy of  syphilis  and  chronic  alcoholism. 

For  the  symptoms  caused  by  chronic 
meningo-encephalitis — or  "periencepha- 
litis," as  preferred  by  certain  writers — 
the  reader  is  referred  to  the  article  upon 
paralytic  dementia,  or  general  paralysis 
of  the  insane;  while  essentially  the  same 
lesions  occurring  in  some  cases  of  chronic 
epilepsy  and  of  terminal  dementia  do  not 
give  rise  to  any  constant  clinical  type. 

It  is  thus  seen  that  the  study  of  the 


ENCEPHALITIS.    CHRONIC.    ETIOLOGY.    PATHOLOGY. 


689 


clinical  symptoms  which  may  arise  upon 
the  pathological  basis  of  chronic  en- 
cephalitis are  many  and  varied,  and  can 
only  be  studied  as  types,  some  of  which 
have  been  indicated  as  most  clearly 
proved  to  exist  as  results  of  an  inflam- 
matory lesion. 

Etiology.  —  The  primary  etiological 
factor  in  cases  of  chronic  encephalitis  is, 
excluding  syphilitic  cases,  almost  always 
obscure,  and  the  exact  nature  of  the  pri- 
mary irritant,  which  we  must  assume  as 
causative,  is  still  a  subject  for  future  in- 
vestigation. There  is,  in  certain  cases, 
probably  an  hereditary  predisposition  or 
weakness  of  the  cerebral  vascular  system, 
owing  to  which  the  changes  in  the  peri- 
vascular connective  tissue  occur  from 
causes  insufficient  to  produce  them  in 
the  ordinary  brain.  This  hereditary 
factor  in  etiology  is  hard  to  prove,  but 
is  frequently  suggested  in  the  clinical 
study  of  the  cases. 

The  obvious  predisposing  causes  of 
chronic  encephalitis  are  those  common 
to  very  many  diseases  of  the  brain,  and 
include  syphilis,  embolism,  traumatism, 
excessive  physical  or  mental  labor, 
anxiety  or  worry,  fright,  the  acute  in- 
fectious diseases;  organic  affections  of 
the  kidneys,  liver,  or  heart;   and  others. 

There  is  little  doubt  that  prolonged 
mental  ovenvork,  especially  if  associated 
with  prolonged  anxiety,  is  capable  of 
loading  to  pronounced  vascular  disturb- 
ance in  the  cerebrum,  thus  furnishing 
the  conditions  upon  which  the  inflamma- 
tory process  may  be  readily  ingrafted. 

Pathology. — So  far  as  is  known,  the 
primary  clianges  in  chronic  encephalitis 
occur  in  the  vascular  (mesodermic)  con- 
nective tissues,  and  other  structures  are 
coincident!  y — or,  more  iisually,  sulse- 
quenthj — attacked.  In  syphilitic  cases 
the  specific  irritant  toxin  probably  acts 
upon  the  nerve-cell,  the  neuroglia,  the 


lymph-connective  system,  and  the  vas- 
cular and  perivascular  tissues;  and  it  is 
further  probable  that  one  or  other  of 
these  elements  sulFer  more  or  less  in  dif- 
ferent cases,  and  that  this  explains  in 
some  degree  the  wide  range  of  syphilitic 
brain-symptoms.  It  would  appear,  how- 
ever, that  chronic  encephalitis  from  all 
causes  is  usually  of  primary  vascular 
origin,  the  pathological  and  clinical  evi- 
dences both  supporting  this  view. 

Post-mortem  examination  in  cases  of 
chronic  encephalitis  reveals  most  com- 
monly atrophy  of  the  affected  part,  with 
hardening  of  the  tissues;  very  rarely  it 
has  revealed  hypertrophy  of  the  convolu- 
tions as  a  result  of  the  inflammation; 
according  to  the  observations  of  Gowers, 
a  type  of  chronic  encephalitis  exists  in 
which  no  macroscopical  change  can  be 
noticed  after  death,  but  in  which  "slight 
diffuse  inflammatory  changes  were  found 
throughout  the  brain-substance  on  mi- 
croscopical examination."  In  certain 
other  cases  the  same  authority  affirms 
that  chronic  encephalitis  may  cause  a 
form  of  chronic  softening,  wliich  has 
already  been  referred  to  in  this  paper. 

The  microscopical  appearances  differ 
according  to  the  stage  of  the  process, 
and  have  already  been  sufficiently  re- 
ferred to  in  describing  the  varieties  of 
the  disease. 

The  real  significance  of  all  of  these 
chronic  changes  remains  the  subject  of 
dispute,  and  able  authorities  on  either 
side  contend,  on  the  one  hand,  for  the 
inflammatory  origin  of  the  lesions  de- 
scribed, while,  on  the  other,  degenera- 
tion is  held  to  be  the  first  step  in  the 
process.  It  seems,  however,  to  the  writer 
that  the  term  "chronic  encephalitis,"  ac- 
cording to  our  present  knowledge,  should 
include  the  clinical  states  to  which  ref- 
erence has  briefly  been  made,  and  that 
the  theories  of  agenesis  and  degenera- 


690 


ENCEPHALITIS.     CHRONIC.    PRENATAL. 


tion  are  very  satisfactory  as  applied  to  a 
great  number  of  other  chronic  brain  con- 
ditions, which  present  analogous  lesions, 
but  in  which  no  inflammatory  stage  is 
known  to  exist.  Continued  and  careful 
clinical  and  pathological  evidence  is 
needed  to  limit  strictly  the  meaning  of 
chronic  encephalitis,  or  positively  to  ex- 
tend it  so  as  to  exclude  more  of  these 
sclerotic  lesions  than  at  present  we  are 
justified  in  applying  to  it. 

Diagnosis. — The  diagnosis  of  chronic 
encephalitis  is  made  from  the  presence 
of  one  or  other  of  its  causes  and  the  as- 
sociation of  its  symptoms.  According 
to  Gowers,  in  rare  cases  of  chronic  en- 
cephalitis, chronic  headache  with  long- 
continued  cerebral  symptoms,  including 
optic  neuritis,  may  simulate  tumor  of  the 
brain.  Hughlings-Jackson  has  reported 
a  case  in  which  such  symptoms  existed 
for  six  months.  These  symptoms  in 
these  rare  cases  of  primary  chronic  en- 
cephalitis may  be  headache,  vertigo,  epi- 
leptic attacks,  transient  loss  of  sight  or 
other  special  senses,  vomiting,  optic 
neuritis,  slight  fever  and  stupor,  followed 
by  coma  and  death.  The  diagnosis  from 
tumor  would  be  made  by  noting  the 
want  of  progressive  nature  of  the  lesion, 
commonly  present  in  tumor,  the  general 
character  of  the  head-pain,  and  other 
symptoms  of  cerebral  irritation,  and  the 
more  definite  focal  symptoms  of  tumor 
would  also  be  wanting. 

The  forms  of  chronic  encephalitis  sur- 
rounding new  growths  or  other  focal 
lesions  need  not  be  discussed,  because 
their  diagnosis  is  that  of  the  primary 
condition  practically. 

Chronic  meningo-encephalitis  does  not 
present  any  very  distinct  clinical  type, 
except  when  present  as  the  lesion  of  par- 
alytic dementia. 

Prognosiii. — In  all  forma  of  chronic 
encephalitis  the  prognosis  is  very  grave; 


in  most  cases  absolutely  hopeless  as  re- 
gai'ds  cure.  All  cases  of  paralytic  de- 
mentia end  fatally,  except  in  extremely- 
rare  instances,  in  which  a  remission  last- 
ing many  years  may  occur.  The  acute 
forms  of  chronic  encephalitis  which  have 
been  mentioned  may  run  prolonged 
courses,  and  death  may  result  from  in- 
tercurrent disease,  but  is  more  usually 
due  to  the  brain  condition  directly  or 
indirectly. 

Treatment. — The  most  hopeful  cases 
of  chronic  encephalitis  clinically  are 
those  resulting  from  syphilis.  In  such 
cases  large  doses  of  the  iodide  of  potas- 
sium combined  with  rest  and  general 
tonic  treatment  sometimes  accomplishes 
extremely  satisfactory  results.  The  rare 
cases  in  which  chronic  encephalitis  is 
suspected  as  a  primary  condition  must 
be  treated  on  the  general  principles  gov- 
erning the  treatment  of  chronic  inflam- 
mation. The  cases  associated  with  other 
focal  cerebral  lesions  require  the  treat- 
ment necessary  to  the  primary  condition 
present. 

Prenatal  Encephalitis. 

The  basis  for  belief  in  a  prenatal  form 
of  encephalitis  is  chiefly  the  studies  of 
Virchow,  who  described  in  1865  whitish 
or  yellowish-gray  foci  in  the  brain  of 
newborn  infants  which  he  considered 
inflammatory  in  origin.  These  foci  he 
describes  as  a  fatty  change  in  the  neu- 
rogliar  cells,  with  unequally-dilated  and 
obstructed  vessels  and  neurogliar  cell- 
proliferation  along  the  vessels.  He  also 
refers  to  a  peculiar  kind  of  softening  in 
connection  with  these  foci.  When  the 
foci  are  situated  in  the  white  substance 
of  the  brain  they  are  grayish-red  in  color, 
from  congestion  of  the  capillaries.  Un- 
less the  lesions  have  progressed  to  the 
stage  of  softening  the  brain-consistence 
is  unaltered.  ITayem,  on  the  contrary, 
regards  fatty  degeneration  of  the  neu- 


ENCEPHALITIS. 


ENCEPHALOCELE. 


691 


rogliar  cells  as  inflammatory  only  when 
associated  with  extreme  congestion  and 
the  compound  granular  cell.  Jastro- 
witz  considers  the  condition  physio- 
logical in  foetal  life,  basing  his  conclu- 
sions upon  a  study  of  sixty-five  cases. 
According  to  him,  this  fatty  degenera- 
tion of  the  neurogliar  cells  does  not  fol- 
low inflammatory  proliferation  as  pro- 
claimed by  Virchow,  but  is  commonly 
found  in  certain  portions  of  the  brain, 
increases  until  the  seventh  month  of 
intra-uterine  life,  and  disappears  soon 
after  birth.  Virchow's  observations  have 
been  confirmed  by  Parrot  and  others,  but 
a  great  difference  of  opinion  exists  re- 
garding the  primary  cause  of  these 
patches.  Eecent  studies  have  demon- 
strated a  form  of  miliarj'  encephalitis  in 
the  newborn  which  is  due  to  septic 
metastasis  from  suppuration  of  the  um- 
bilical cord,  and  other  cases  are  reported 
in  which  this  lesion  has  followed  diph- 
theria and  aphthous  stomatitis,  some 
authorities  regarding  this  form  of  en- 
cephalitis as  the  primary  stage  of  the 
lesions  found  in  a  proportion  of  the  cases 
of  spastic  hemiplegia  and  diplegia,  and 
in  some  cases  of  disseminated  sclerosis 
in  children. 

Charles  M.  Hat, 

Philadelphia. 

ENCEPHALOCELE.— Gr.,  eyxe^a'koc, 

the  brain,  and  x>7 /*->;,  a  tumor. 

Definition  and  Varieties. — Encephalo- 
cele,  or  hernia  cerebri,  means  a  protrusion 
of  a  portion  of  brain-substance  with  its 
membranes  through  an  aperture  in  the 
skull,  congenital  in  origin,  and  usually 
situated  in  the  occipital  region  in  the 
median  line,  less  frequently  in  the  naso- 
frontal rc.gion,  and  rarely  in  other  situ- 
ations. Meningocele  and  hydrencephalo- 
ccle  are  closely  allied  conditions.  Men- 
ingocele means  a  protrusion  of  a  portion 


of  the  membranes  of  the  brain  through 
an  opening  in  the  skull,  the  sac  thus 
formed  being  distended  by  cerebro- 
spinal fluid.  Hydrencephalocele  means  a 
protrusion  of  the  membranes  and  brain- 
substance,  which  also  contains  within  il 
a  cavity  continuous  with  the  lateral  ven- 
tricles of  the  brain,  and  filled  with  cere- 
bro-spinal  fluid.  The  latter  condition  is 
the  gravest  and  the  most  frequent  in 
occurrence  of  the  three,  encephalocele 
being  next  in  frequency,  and  meningo- 
cele the  rarest.  All  of  these  conditions 
are  of  very  rare  occurrence.  Forms  of 
acquired  hernia  cerebri  will  more  prop, 
erly  be  considered  elsewhere,  in  connec- 
tion with  the  various  causes  of  this  con. 
dition. 

Symptoms. — In  the  three  forms  enu- 
merated the  disease  is  congenital,  and  is 
developed  at  some  period  of  intra-uter 
ine  life;  and  at  birth  presents  a  tumor  of 
varying  size,  generally  situated  in  the 
occipital  region,  or  in  the  naso-frontal 
region  in  the  median  line.  In  almost  all 
cases  the  hernia  emerges  through  an 
opening  in  the  line  of  one  of  the  cranial 
sutures. 

Tlie  naso-frontal  hernias  leave  the 
cranium  between  the  frontal  and  nasal 
bones  and  form  a  tumor  in  the  median 
line  in  the  region  of  the  glabella. 

The  nasoethmoidal  hernias  leave  the 
cranium  between  the  frontal  and  nasal 
bones  on  the  one  side  and  the  lateral 
mass  or  labyrinth  on  the  other,  which 
is  forced  or  displaced  downward  toward 
the  nasal  cavity.  The  tumor  appears 
externally  in  the  region  of  the  border 
between  the  osseous  and  cartilaginous 
portions  of  the  nose,  hanging  down 
toward  the  tip  or  the  wing  of  the  nose. 
The  naso-orbital  hernias  leave  the 
cranium  between  the  frontal,  ethmoid, 
and  lacrymal  bones.  In  the  region  of 
the  latter  they  enter  the  orbit  and  pre- 
sent at  or  near  the  inner  canthus  of  the 
eye.  The  naso-cthmoidal  and  naso-orbital 
varieties  are  probably  not  distinguish- 
able from  each  other,  as  they  leave  the 


692 


EXCEPHAT.OCELE.    SYMPTOMS. 


cranium  at  the  same  place,  namely:  the 
nasal  notch  of  the  frontal  and  the  cribri- 
form plate  of  the  ethmoid  bone.  Chris- 
tian Fenger  (Amer.  Jour.  Med.  Sci.,  Jan., 
'95). 

Cephalhsematoma  represents  one  of 
the  risks  through  which  the  child  must 
pass  during  labor.     The  tumor  consists 


Palatine  hydrencephalocele  in  a  newborn 
child.  (Yirchow,  Die  Krankhaften 
Gescliwiilste.) 

of  an  infusion  of  blood  between  the  peri- 
osteum and  bone,  forming  either  two 
projections  over  the  parietal  bosses  or 
more  commonly  a  single  projection  upon 
one  side.  It  is  important  to  distinguish 
this  condition  from  a  sero-sanguinolent 
effusion,  which  is  much  more  common, 
and  which  is  present  at  birth.  This 
tumor  is  soft,  but  less  fluctuating,  and 
can  be  indented  by  the  finger,  as  in 
oedema.  It  appears  on  the  presenting 
portion  of  the  foetus,  therefore  is  formed 
before  its  expulsion,  and  disappears 
shortly  after  birth — within  one  or  two 
days.  It  never  limits  itself,  as  does  the 
cephalhffimatoma,  to  the  border  of  the 
bones.  The  characteristics  of  the  sero- 
sanguinolent  tumors  are  exactly  oppo- 
site to  those  of  cephalhematoma.  It 
is  due  to  a  circular  compression  at  tlio 
base  of  the  part  which  corresponds  to 
the  ring  of  the  pelvis  during  engage- 
ment, and  always  appears  before  the 
presenting  part.  Queircl  (Annalea  do 
GynCc.  et  d'Obstet.,  Jan.,  1901). 


Of  93  cases  collected  by  Houel,  68 
cases  were  occipital,  16  were  fronto-nasal, 
and  9  occurred  in  other  situations;  while 
of  105  cases  collected  by  Schatz,  59  were 
occipital  and  -16  frontal.  These  hernial 
protrusions  may  occur  in  other  situa- 
tions. Thus,  in  the  frontal  region  in- 
stead of  emerging  between  the  cribiform 
plate  of  the  ethmoid  and  the  frontal 
bone,  such  a  protrusion  is  sometimes  lo- 
cated in  the  interfrontal  fissure  high  up, 
or  in  the  anterior  fontanelle;  less  fre- 
quently they  occur  in  the  sagittal  suture, 
or  between  the  temporal  and  parietal 
bones,  thus  appearing  upon  the  side  of 
the  head.  The  frontal  tumors  are 
smaller,  as  a  rule,  than  the  occipital 
growths,  and  are  covered  with  a  more 
vascular  skin  covering;  so  that  they  may 
give  the  appearance  of  certain  forms  of 
nffivus.  In  extremely  rare  cases  the 
opening  has  existed  between  the  sphe- 
noid and  ethmoid  bones,  or  between  th& 
sphenoid  and  its  greater  wing. 


Encephalocele.      (Holt,  "Diseases  of  Infancv 
and  Childhood.") 


The  tumor  may  thus  appear  in  the 
pharynx,  or  in  the  mouth,  or  protrude 
through  the  spheno-maxillary  fissure,  or 
into  the  orbit,  causing  displacement  of 
the  eye. 

The  physical  characteristics  of  the 
three-  forms  of  congenital  tumor  differ 


ENCEPHALOCELE.    SYMPTOMS. 


G93 


according  to  the  size  of  the  opening  in 
the  skull  and  the  nature  of  their  con- 
tents. Owing  to  possible  error  in  diag- 
nosis, all  tumors  of  this  kind  should  re- 
ceive most  careful  physical  examination, 


Nasofrontal    meningocele.      [Unit,    "Diseases 
of  Infancy  and  Childliood.") 

especially   if   any   surgical   interference 
should  be  contemplated. 

(a)  Encephalocele  presents  the  small- 
est tumor  of  the  three,  usually  rounded 
or  oval  with  a  broad  base,  and  having  a 
pretty    firm    resistance    to    the    touch. 


Occipital    meiiiiigocLle.      [Uutl,  -DiiirdSCS   Of 
Infancy  and  Childhood.") 

Sometimes  the  tumor  is  marked  by  a 
median  furrow,  dividing  it  into  two 
lateral  halves.  The  tumor  is  opaque, 
does  not  fluctuate,  has  distinct  pulsation 
synchronous  with  the  heart's  action,  and 


pressure  upon  it  causes  symptoms  of 
cerebral  compression,  such  as  nausea, 
vomiting,  irregular  respiration,  strabis- 
mus, and  even  convulsions. 

(6)  Meningocele  appears  as  a  more 
uniformly  round  or  oval  pedunculated 
tumor,  usually  small  at  birth  and  subse- 
quently increasing  more  or  less  in  size. 


Diagram  of  meningocele.     (Holt,  "Diseases  of 
Infancy  and  Childhood.") 

It  is  translucent,  fluctuates  distinctly, 
does  not  pulsate,  is  made  intense  on  the 
crying  of  the  child,  or  during  forced  ex- 
piratory eff'orts,  and  it  is  reducible  upon 
pressure. 


Hydrencephalocele.      {Uolt,   "Diseases  of 
Infancy  and  Childhood.") 

(c)  Hydrencephalocele  presents  the 
largest  tumor  of  the  three  forms  of  this 
condition.  The  tumor  is  lobulated, 
pendulous,  and  more  or  less  peduncu- 


694 


ENXEPHALOCELE.    DIAGNOSIS.    PKOGNOSIS.    TREATMENT. 


lated;  and  there  is  fluctuation,  translu- 
cency  of  parts  of  the  tumor,  according 
to  the  amount  and  location  of  the  liquid 
contained  within  it,  and  usually  absence 
of  pulsation.  The  surface  of  the  mass 
is  covered  with  hair  if  the  tumor  is  small, 
but  if  large  the  hair  is  only  about  its 
base,  being  absent  over  its.  fundus.  It  is 
liable  to  increase  of  size  and  to  final  rupt- 
ure with  rapid  collapse  or  convulsions 
prior  to  death.  Pressure  does  not  pro- 
duce the  marked  signs  of  cerebral  com- 
pression observed  in  cases  of  encephalo- 
cele.  In  some  cases  some  form  of  pa- 
ralysis may  also  be  present,  with  micro- 
cephalus  and  hydrocephalus. 

Differential  Diagnosis. — Any  of  these 
conditions  may  possibly  be  confounded 
with  cephalhfflmatoma,  serous  or  seba- 
ceous cysts,  abscesses,  ntevi,  and  polypi. 
Such  mistakes  having  been  made,  it  is 
most  important  that  the  most  careful  ex- 
amination should  precede  any  surgical 
interference;  but,  with  ordinary  care  and 
attention  to  the  physical  characteristics 
of  these  forms  of  hernia  cerebri,  mistakes 
of  this  kind  should  never  occur.  The 
diagnosis,  therefore,  is  usually  a  simple 
matter,  and  is  readily  made  upon  careful 
examination  of  the  tumor.  The  fact  that 
these  conditions  usually  occur  in  the 
median  line,  that  meningocele  is  redu- 
cible, that  encephalocele  is  attended  by 
signs  of  cerebral  compression  when  press- 
ure is  made  upon  the  tumor,  and  pul- 
sates distinctly,  and  that  all  of  them 
are  made  tense  upon  forced  expiration, 
should  separate  them  from  any  of  the 
above  conditions.  In  many  of  the  cases 
the  edges  of  the  bony  opening  through 
which  the  protrusion  occurs  can  be  felt 
by  palpation,  with  partial  reduction  by 
pressure.  I/ydrencephalocele  can  hardly 
be  confounded  with  any  of  the  above 
affections,  owing  to  its  large  size,  its 
pendulous,  pedunculated,  and  lobulated 


conformation,  with  semitranslucency, 
and  its  strictly  congenital  history.  All 
of  these  cases  are  apt  to  be  associated 
with  other  deformities,  and  some  form 
of  paralysis  is  frequently  present  in  cases 
of  hydrenceplialocele. 

Etiology  and  Pathology. — The  excit- 
ing causes  of  these  three  forms  of  con- 
genital malformations  are  practically  un- 
known. It  is  probable  that  injury  to  the 
mother  may  account  for  some  of  the 
cases.  The  influence  of  certain  maternal 
impressions  may  operate  here,  by  in- 
ducing an  arrest  of  development. 

The  most  widely  accepted  view  of  the 
pathology  of  these  states  is  that  they  are 
all  due  to  a  primary  intra-uterine  hydro- 
cephalus, and  that  the  resultant  in- 
creased intracranial  pressure  during  the 
closure  of  the  cranial  cavity  causes  a  por- 
tion of  the  intracranial  contents  to  be 
forced  outside,  an  aperture  being  main- 
tained. Other  possible  causes  are  am- 
niotic adhesions  to  the  scalp  of  the  foetus, 
and  arrest  of  development  in  the  bones 
concerned.  This  arrest  of  bony  develop- 
ment may  be  caused  by  amniotic  adhe- 
sions. However,  the  fact  that  these  pro- 
trusions occur  in  the  median  line  favors 
hydrocephalus  as  the  causative  condi- 
tion. 

Prognosis. — The  prognosis  is  unfavor- 
able, except  in  cases  of  small  meningo- 
cele amenable  to  operation,  and  in  cases 
of  small  encephalocele,  some  of  which 
live  for  many  years.  Ilydrencephalocele 
is  usually  a  fatal  condition,  death  occur- 
ring in  from  a  day  or  two  to  several 
weeks. 

Treatment. —  Meningocele  has  been 
frequently  aspirated,  and  the  injection 
of  iodine  into  the  sac  in  the  form  of 
Morton's  solution  has  been  practiced. 
Many  forms  of  operation  have  been  tried 
in  these  cases,  and  successful  operations 
have  been  reported  from  all  of  them,  but, 


EXCEPHALOCELE.    TREATMENT. 


695 


even  in  the  successful  cases,  chronic  hy- 
drocephalus has  often  followed. 

Attempts  at  the  removal  of  encepbalo- 
cele  by  operation  have  been  made  by 
Lichtenberg,  Czcrny,  and  tlie  author. 
Lichtenberg's  patient  died  from  the  op- 
eration; Czerny's  patient  survived  the 
operation,  but  died  later  from  apparently 
independent  causes. 

Personal  case  in  which  the  patient 
made  a  permanent  recovery:  that  of  a 
Swede,  in  whom  was  found  a  tumor 
filling  the  post-nasal  space  above  the 
soft  palate.  On  palpation  the  tumor 
seemed  somewhat  compressible,  and 
would,  upon  pressure,  appear  to  decrease 
in  size  so  that  it  could  be  pushed  up 
into  the  left  half  of  the  posterior  nares. 
The  pedicle  could  be  traced  to  the  roof 
of  the  nose.  Cerebral  hernia  suspected. 
Hypodermic  needle  twice  inserted  with 
negative  results  and  diagnosis  of  ordi- 
nary polypus  and  not  basal  hernia  made. 
An  attempt  made  to  remove  the  growth 
in  the  usual  way  witli  the  wire  snare 
and  the  pedicle  divided.  After  with- 
drawal of  the  snare  slight  hfemorrhage 
occurred,  but  neither  coughing  nor 
sneezing  brought  forth  the  tumor.  The 
hoemorrhage  soon  ceased,  but  was  im- 
mediately lollowcd  by  dripping  of  a  clear 
watery  fluid,  of  which  about  a  teaspoon- 
ful  was  collected.  The  fluid  was  cere- 
bro-spinal.  The  basis  of  the  plan  of  op- 
eration now  was  to  secure  the  pedicle 
for  transfixion  and  ligature  as  close  to 
its  exit  from  the  cranium  as  possible. 
The  operation  of  the  osteoplastic  or  tem- 
porary resection  of  the  superior  maxilla 
as  devised  by  von  Langenbeck  was  ac- 
cordingly executed.  Ten  weeks  after  the 
operation  the  wound  was  so  nearly 
closed  that  collodion  dressing  could  be 
applied  over  the  fistula  lending  into  the 
antrum,  which  remained  open  for  about 
three  months,  but  secreted  little  and  did 
not  interfere  with  the  patienfs  work  as 
coachman. 

The  microscopical  examination  showed 
distinctly  that  the  tumor  was  a  cysto- 
encephaloccle.  Although  no  layer  of 
white  brain-substance  was  present,  there 
was  no  doubt  that  this  cavity  was  a 
contin\iation  of  a  ventricle,  probably  the 
third  ventricle.     Its  regular  shape,  and 


the  fact  of  its  being  entirely  surrounded 
by  a  layer  of  cortical  brain-substance, 
made  it  distinctly  difTerent  from  the 
serous  cavities  which  are  found  in  her- 
nias of  the  brain  as  well  as  of  the  spinal 
cord,  developed  from,  or  an  exaggeration 
of,  the  subarachnoid  lymph-spaces. 

The  distance  between  the  eyes  a  point 
in  diagnosis.    It  is  possible  that  a  basal 
cerebral  hernia  might  cause  a  broaden- 
ing of  the  root  of  the  nose  and  a  corre- 
sponding  increase    in    the   distance    be- 
tween the  inner  walls  of  the  orbits,  just 
as  occurs  in  sincipital   hernias.     Chris- 
tian Fenger  (Amer.  Jour.  Med.  Sci.,  .Jan., 
'95). 
Treves  operates  in   these   cases  only 
when    rupture    is    threatened.     Schatz 
(Berliner  klin.  Woch.,  No.  28,  '8.5)  gives 
statistics    as    follows:    3    recoveries    in 
24  occipital  tumors  not  operated  on,  and 
6  recoveries  from  35  operated  on  by  in- 
jection, clamp  or  ligature,  or  excision. 
Six  recovered  out  of  46  frontal  tumors 
without  operation,  while  2  recovered  out 
of  14  operated  on.     The  tendency  at 
present  is  to  operate  upon  these  cases, 
although  the  results  are  not  very  encour- 
aging. 

When  the  tumor  is  not  small,  it  should 
be  supported  by  gentle  pressure, — or  a 
collodion  dressing  may  be  applied  over 
it,  as  advised  by  some  surgeons. 

In  the  case  of  a  small  encephalocele  it 
is  better  to  apply  gentle  pressure,  and  to 
wait  in  order  to  find  out  if  it  inclines  to 
enlarge.  In  this  form  the  patient  may 
live  many  years  and  experience  no  dis- 
comfort from  the  condition. 

Cases  of  spontaneous  cure  of  encepha- 
locele and  meningocele  have  been  re- 
ported. This  is  effected  by  gradual 
gro^-th  of  bone  around  the  opening,  with 
retraction  of  the  sac.  The  opening  in 
some  cases  becomes  entirely  closed.  This 
is,  however,  of  very  infrequent  occur- 
rence. 

Charles  M.  ITat, 

Philadelphia. 


696 


ENDOMETRITIS.     VAKIETIES.     SYMPTOMS. 


ENCHONDKOMA.     See  Tumobs. 

ENDOCARDITIS.  See  YALvaLAB 
Diseases  and  Index. 

ENDOMETRITIS.— Gr.,  h'Sov,  within, 
and  urrpa,  the  uterus. 

Definition. — An  inflammation  or  hy- 
perplasia of  the  uterine  mucous  mem- 
brane involving,  to  a  greater  or  less  ex- 
tent, the  parenchyma  of  the  uterus. 

Varieties. — It  is  convenient,  both  in  a 
clinical  and  a  pathologic  sense,  to  divide 
the  disease  into  two  varieties,  viz.:  (1) 
interstitial  or  functional  endometritis; 
and  (2)  glandular  or  functional  endome- 
tritis, or  hyperplasia.  Either  of  these 
two  varieties  may  exist  in  the  acute  and 
chronic  form,  but  the  chronic  form  may 
follow  a  mild  and  overlooked  acute  at- 
tack, or  may  supervene  in  a  gradual  man- 
ner without  being  preceded  by  a  recog- 
nizable acute  attack. 

Tliere  are  three  varieties  of  endome- 
tritis: the  glandular,  interstitial,  and 
fungous.  The  form  described  as  endo- 
metritis decidua  is  a  combination  of  the 
glandular  and  interstitial  forms,  while 
gonorrhoea!  endometritis  is  of  the  inter- 
stitial variety  and  similar  to  senile 
endometritis.  Winckel  (Munchener  med. 
Woch.,  July  al,  '94). 

Endometritis  is  exceedingly  rare;  only 
about  one  case  in  fifty  that  come  to  the 
clinics  is  really  endometritis.  II.  A. 
Kelly   (Med.  Record,  May  21,  '98). 

Patients  with  painful  endometritis  are 
apt  to  complain  of  general  ncn'ous  symp- 
toms rather  than  local;  hence  they  are 
often  regarded  as  purely  neurotic.  This 
error  is  also  due  to  superflcial  examina- 
tions and  the  failure  to  test  the  sensitive- 
ness of  the  endometrium,  the  uterus 
being  regarded  as  normal  because  it  is 
not  enlarged.  Tliere  is  an  intimate  re- 
lation between  the  sympathetic  nerves 
of  the  pelvis  and  the  lumbar  plexus,  as 
shown  by  the  pains  on  the  inner  aspect 
of  the  thighs  in  connection  with  painful 
endometritis.  SneguirefT  (.Archiv  f. 
Gynilk.,  B.  59,  H.  2,  1900). 


Symptoms. — The  symptoms  may  be 
divided  into  (1)  disturbances  of  the  sex- 
ual fimctions,  (2)  intermenstrual  dis- 
charges, (3)  pain  and  discomfort  in  and 
about  the  uterus  or  radiating  from  the 
uterus,  (4)  reflex  disturbances,  and  (5) 
general  symptoms. 

Menorrhagia  is  one  of  the  most  fre- 
quent symptoms  in  the  early  stages  and  in 
the  glandular  variety  it  often  persists  for 
a  long  time  as  the  most  prominent  one. 
The  flow  may  be  moderately  increased  in 
amount,  or  be  a  profuse  hemorrhage 
with  the  passage  of  clots;  it  may  be  pro- 
longed, or  may  recur  too  often.  In  the 
later  stages  of  septic  or  interstitial  en- 
dometritis the  menses  are  sometimes 
scanty.  In  certain  acute  attacks  the 
menstrual  flow  is  suppressed. 

Dysmenorrhoea  is  common  in  cases 
connected  with  flexion,  puerile  cervix,  or 
inflammation  of  the  appendages. 

Dysmenorrhoea  and  menorrhagia  from 
wliicli  many  young  girls  suffer  are  due 
to  endometritis,  and  the  chief  causes 
leading  to  this  condition  are  tight  cor- 
sets, exijosure  of  the  feet  to  wet  and 
cold,  chronic  constipation.  A.  Lapthorn 
Smith  (Amer.  Medico-Surg.  Bull.,  May 
30,  '96). 
Dyspareunia  and  sterility  may  be  pres- 
ent under  the  same  conditions. 

Sterility  in  woman  is  most  frequently 
due  to  catarrhal  endometritis,  resulting 
from  a  previous  miscarriage.     The  prin- 
cipal causes  are:  the  absence  of  a  suit- 
able liabitat  for  the  ovum  in  the  uterine 
cavity;  obstruction  of  the  cervical  canal 
by   mucus;   and  increased  alkalinity  of 
the  cervical  secretions,  corresponding  to 
an  exaggerated  alkaline  condition  of  the 
vaginal  mucus.     W.  P.  Manton   (Amer. 
Jour,  of  Obst.,  No.  4,  '92). 
Leucorrhoca  is  usually  noticeable  in 
the  glandular  variety  and  in  the  early 
stages  of  the  septic.    In  the  former  the 
corpus  secretes  a  thin,  and  the  cervix  a 
thick,  clear  mucus,  both  of  which  may 
bo  transformed  into  minute  white  co- 


ENDOMETRITIS.    DIAGNOSIS. 


697 


agula,  at  the  external  os,  by  the  acid 
vaginal  secretion,  and  appear  at  the 
vulva  as  a  white  or  greenish-white  dis- 
charge. In  some  cases  the  mucus  is 
intermittingly  tinged  with  blood.  The 
leucorrhcea  may  last  throughout  the 
month,  or  only  for  a  few  days  after  the 
cessation  of  the  monthly  flow.  In  the 
septic  variety  the  discharge  is  at  first 
purulent,  but  later  becomes  muco-puru- 
lent,  and  in  time  may  be  mucous  or  even 
watery  in  character.  It  sometimes  has  a 
disagreeable  odor. 

Pain  may  be  felt  in  the  sacral  or  lum- 
bar region,  and  may  extend  across  the 
back  or  up  the  spine  to  the  occipital 
region,  or  down  the  course  of  the  sciatic 
nerve.  Cutting  or  cramping  pains  across 
the  lower  abdomen  or  pubic  region  may 
be  complained  of,  depending  upon  pain- 
ful uterine  contractions  due  to  the  expul- 
sion or  attempted  expulsion  of  uterine 
discharges.  Irritability  of  the  bladder  or 
rectum,  or  pain  in  the  vagina  or  pubic 
bones,  may  be  prominent.  Feelings  of 
weight  in  the  vagina,  and  sensations  as 
of  prolapse  of  the  pelvic  organs  are  pres- 
ent in  some  cases.  Intercostal  neuralgia 
is  not  uncommon. 

Menstrual  pain  of  a  burning  or  aching 
character  may  be  felt  in  the  pelvis  and 
back,  or  the  pain  may  be  suprapubic  and 
colicky.  It  may  last  one  or  more  days  oi 
throughout  the  period,  and  even  for  sev- 
eral days  afterward.  '\^1ien  the  mucous 
membrane  is  exfoliated  the  uterine  con- 
tractions are  frequent  and  excessively 
painful,  and  last  until  the  membrane  is 
expelled. 

Gaseous  distension  of  the  intestines, 
constipation,  impaired  digestion — with 
its  accompanying  reflexes,  photophobia, 
and  pain  in  the  eyes  after  prolonged  at- 
tempts at  reading — are  the  ordinary  re- 
flex disturbances.  Jlental  depression, 
worry,  and  the  various  manifestations  of 


hysteria  and  neurasthenia  are  sometimes 
classed  among  the  reflexes,  although 
they  are,  as  a  rule,  largely  dependent 
upon  other  conditions  and  circumstances. 
Chills,  fever,  and  the  other  general 
sjTnptoms  of  inflammation  and  sepsis  are 
observed  in  acute  endometritis. 

In  chronic  cases  ana;mia  and  nervous 
debility  are  often  present. 

Diagnosis. — Endometritis  must  be  dif- 
ferentiated from  angioma,  tuberculosis, 
carcinoma,  and  myoma  of  the  uterine 
mucous  membrane. 

Besides  the  symptoms,  tenderness  of 
the  uterus,  as  evidenced  by  bimanual 
palpation,  and  sensitiveness  of  the  endo- 
metrium at  the  internal  os  and  fundus, 
as  demonstrated  by  the  passage  of  the 
sound,  are  of  diagnostic  value.  The 
withdrawal  of  the  sound  may  be  followed 
by  a  moderate  flow  of  blood  or  mucus. 

Differential  diagnosis  between  catarrh 
limited  to  the  cervix  and  cervico-cor- 
poreal  catarrh:  (1)  thin,  purulent  dis- 
charge indicates  catarrh  of  corporeal  en- 
dometrium; (2)  cervical  catarrhs  sel- 
dom occur  in  multiparre;  (3)  reflex 
symptoms  point  to  trouble  of  mucosa; 
(4)  cervical  catarrhs  are  rare  in  virgins, 
cervical  and  corporeal  catarrh  still  more 
so.  Van  Tussenbroek  and  de  Leon 
(Archiv  f.  GynUk.,  B.  47,  '94). 

Endoscopy  recommended  in  the  study 
of  cndo-uterino  alTections;  the  technique 
is  not  dillicult.  Bumm  (La  Semaine 
MCd.,  June  15,  '95). 

[It  is  certainly  doubtful  whether  the 
examination  of  the  uterus  by  the  endo- 
scope affords  information  that  justifies 
the  dangers  of  carrying  infection  to  the 
uterine  cavity.  E.  E.  Montgomery, 
Assoc.  Ed.,  Annual,  '00.] 

The  pronounced  tenderness  of  the  en- 
dometrium on  the  touch  of  the  sound  is 
characteristic  of  painful  endometritis. 
As  a  rule,  only  certain  localities  (fundus 
and  tubal  insertions)  give  rise  to  the 
attacks  of  pain.  The  use  of  the  curette 
brought  recovery;  a  glandular  hyper- 
plasia could  generally   be  found  in  the 


698 


EKDOMETRITIS.    ETIOLOGY. 


debris.  Pinkuss  (Monats.  f.  Geb.  u. 
Grn.,  B.  11,  S.  90S,  1900). 
It  is  difficult  to  distinguish  AXGiOiiA 
from  hemorrhagic  glandular  endome- 
tritis except  by  the  aid  of  the  curette, 
which,  in  the  latter  case,  will  bring  out 
some  of  the  hyperplastic  mucous  mem- 
brane. 

In  TUBERCULOSIS  of  the  endometrium 
the  curette  will  find  necrotic,  cheesy  par- 
ticles and  perhaps  tuberculous  tissue. 
An  accompanying  bilateral  salpingitis 
and  pelvic  peritonitis  with  encysted 
ascites,  particularly  in  virgins,  indicate 
the  condition.  Tuberculosis  elsewhere, 
and  a  slowly  progressive  anaemia,  add 
probability. 

In  CARCINOMA  and  sarcoma  watery 
discharges,    fcetor,    gradually-increasing 
metrorrhagia,  rapid  progress  and  the  mi- 
croscopical examination  of  the  findings 
of  the  curette  are  diagnostic.     Carcino- 
matous infiltration  of  the  cervix  produces 
a  globular  enlargement  that  affects  the 
supravaginal  portion  as  much  or  more 
than  the  vaginal.    Carcinomatous  ulcer- 
ation is  excavated,  fissured,  pale  red  or 
grayish,  with  vascular  spots  that  are  fri- 
able and  bleed  easily  upon  being  touched. 
A  tenaculum  tears  it  easily  and  causes 
abundant    haemorrhage,    but   will    hold 
firmly    in    an    inflamed    cervix.     ^V^len 
there  is  cystic  degeneration  the  tenacu- 
lum may  tear  out  easily,  but  it  causes  a 
flow  of  mucus  from  the  lacerated  follicles 
with  or  without  some  hemorrhage.    The 
inflamed  cervix  is  usually  soft  and  elastic, 
the  carcinomatous  either  hard  or  friable. 
Two     cases    of    endometritis     closely 
simulating  cancer  of  the  fundus  in  order 
to   emphasize   the   fact  that  the   micro- 
scope as  a  means  of  exclusion  is  quite 
as  valuable  as  in  the  positive  diagnosis 
of  cancer.     The  microscopical  examina- 
tions  of   uterine   scrapings   in   cases   of 
suspected   carcinoma   may   be   of   value 
in  differential  diagnosis  either  as  a  posi- 
tive or  negative  factor.     It  is  positive 


when    the    examination    shows    without  • 
question  the  presence  of  cancer;    it  is 
of  just  as  great  value  when  it  as  cer- 
tainly  reveals   the   benign  nature   of   a 
pathological    process    which    has    given 
rise  to  symptoms  characteristic  of  can- 
cer.     Anspach    (Univ.    of    Penna.    Jled. 
Bull.,  May,  1901). 
Small    intra-uterine    and    submucous 
mtomata  usually  cause  marked  enlarge- 
ment  of   the   uterine   cavity,   and   can 
sometimes  be  felt  by  the  sound.     Digi- 
tal   examination    of    the    endometrium 
through  the  dilated  and  incised  cervix  is 
of  great  value  in  discovering  this,  as  also 
of  other  conditions,  although  the  pro- 
cedure is  a  mutilating  one  and  only  ad- 
visable in  rare  instances. 

Etiology. — Acute  endometritis  may  re- 
sult from  trauma  or  taking  cold  during 
the  menstrual  congestion,  such  as  sup- 
pression of  menstruation  from  exposure 
to  cold,  excessive  coitus,  overexertion,  or 
blows  upon  the  lower  abdomen  during' 
menstruation.  It  may  also  be  caused  by 
infection,  such  as  inoculation  by  gonor- 
rhceal  pus  during  or  following  coitus,  in- 
fection of  retained  secundines,  or  the  ex- 
tension of  sepsis  from  vaginal  inflamma- 
tion. 

Bacteriological  examination  of  the  en- 
dometrium in  twenty-five  cases  of  endo- 
metritis made  and  fourteen  distinct  spe- 
cies of  micro-organisms  were  found. 
Brandt  (Med.  Chronicle,  Apr.,  '92). 

The  pyogenic  form  is  most  common  in 
puerpera;.  The  streptococcus  pyogenes 
is  nearly  always  the  active  agent,  though 
staphylococci,  gonococci,  and  the  bac- 
terium coli  commune  may  be  etiological 
factors.  DiJderlcin  (Centralb.  f.  Gynilk., 
No.  20,  '95). 

ICiidometritis  is  the  result  of  infection 
with  pathogenic  micro-organisms  which 
are  carried  into  the  uterus'  during  the 
puerperal  stale,  by  means  of  examina- 
tions with  unclean  instruments;  by 
moans  of  sterilized  instruments  used 
in  the  vagina  which  has  not  been  disin- 
fected; by  the  gonococcus  in  about  35 
jier  cent,  of  the  cases,  and  by  the  bacillus 


ENDOMETKITIS.    ETIOLOGY. 


699 


of  tuberculosis  in  12  per  cent.  Every 
case  should  be  submitted  to  radical 
treatment  by  means  of  the  sharp  curette 
and  drainage  with  iodoform  gauze.  J. 
T.  Jelks  (Inter.  Jour,  of  Surg.,  Feb.,  '90). 
One  hundred  and  seventy-nine  cases 
of  puerperal  endometritis  studied  and 
placed  in  three  principal  groups:  — 

1.  Pyogenic  form  due  to  streptococcus 
pyogenes  (74  cases) ;  the  pyogenic  form 
due  to  staphylococcus  pyogenes  aureus 
(4  cases). 

2.  Gonorrhoeal  form   (50  cases). 

3.  "Putrid"  form  due  to  saprogenic 
bacteria  (50  cases). 

Six  fatal  cases  recorded,  and  in  all  the 
infection   was   due   to   streptococci.     In 
some  of  the  eases  the  infection  appeared 
to  be  of  a  mi.\ed  form.     KrOnig   (I'Ob- 
stetrique,  Jan.,  '97). 
Endometritis  may  also  follow  trauma- 
tism with  immediate  or  subsequent  infec- 
tion, such  as  lacerations  of  the  cervix 
during  labor  or  by  instrumental  dilation, 
curettage  of  the  endometrium,  the  in- 
troduction into  the  uterus  of  strong  irri- 
tants,   the   use    of   intra-uterine   stem- 
pessaries  or  poorly-fitting  vaginal  pes- 
saries, irritating  and  unclean  tampons, 
etc. 

Experiments  demonstrating  the  bac- 
tericidal property  of  vaginal  secretion. 
With  the  exception  of  the  gonococcus, 
bacteria  cannot  vegetate  for  any  con- 
siderable length  of  time  in  the  uterine 
canal.  Menge  (Deutsche  med.  Woch., 
Nos.  40  and  48,  '94). 

In  twenty-nine  cases  of  endometritis  of 
body  no  trace  of  bacteria  found  by  micro- 
scopical examination  or  cultivation.  Dis- 
ease of  mucous  membrane  not  therefore 
kept  up  by  bacteria  in  this  region.  This 
docs  not  exclude  the  fact  that  disease  of 
the  mucous  membrane  arises  from  acute 
septic  or  gonorrheal  infection.  Bumm 
(Centralb.  f.  Gynllk.,  No.  20,  '95). 

Secretion  obtained  from  the  cavity 
of  the  uterus  of  00  cases  and  examined 
microscopically  and  by  cultures  with  the 
following  results:  In  21  patients,  mostly 
cases  of  fungoid  endometritis,  no  bacteria 
were  found,  and  in  most  of  the  cases 
repeated  examinations  gave  negative  re- 
sults.   Seven  of  the  21  cases  showed  the 


presence  of  bacteria  of  some  kind  after 
frequent  intra-uterine  manipulation, 
probably  due  to  inoculation  by  the  in- 
struments. The  bacteria,  however,  were 
not  pathogenic.  The  39  remaining  cases 
in  which  bacteria  were  found  may  be 
divided  into  two  groups:  those  in  which 
staphylococci  were  found  and  those  in 
which  non-pathogenic  bacteria  were  pres- 
ent. Streptococci  were  absent  in  all 
cases  examined.  S.  Gottschalk  and  Rob- 
ert Immerwahr  (Archiv  f.  Gyn.,  No.  3, 
p.  400,  '90). 

Case  of  a  woman  in  which  cause  of 
endometritis  was  found  to  be  the  pres- 
ence of  oxyuris  vermicularis  in  the  vagina 
and  uterus.  E.  M.  Simons  (Centralb.  f. 
Gynilk.,  July  1,  '99). 

Repeated  examinations  of  the  cast 
from  a  ease  of  membranous  dysmenor- 
rhoea  showed  numerous  fresh  venous 
thrombi  in  the  uterine  mucosa,  sim- 
ilar to  the  thrombi  found  in  the  de- 
cidua  in  cases  of  premature  separation 
of  the  placenta.  Curetting  and  caustics 
were  not  curative,  but  cardiac  tonics, 
gj-mnastics,  diet,  baths,  brought  about 
recovery.  Gottschalk  (Deutsche  med. 
Wochen.,  Nov.  20,  1903). 

Traumatism  or  reinfection  may  con- 
vert a  chronic  into  an  acute  endometritis. 
Poisons,  such  as  phosphorus  and  the  es- 
sential oils,  are  occasional  causes. 

Glandular  endometritis  may  be  caused 
by  interference  with  the  menstrual  func- 
tion by  taking  cold,  overexertion,  coitus, 
laborious  or  sedentar)'  occupations,  uter- 
ine displacements,  obstinate  constipa- 
tion, etc.  The  same  causes  may  act  dur- 
ing puerperal  involution  or  after  abor- 
tion. 

There  is  no  specific  organism  for  endo- 
metritis of  pregnancy,  which  is  always 
secondary  and  always  in  existence  be- 
fore the  pregnancy.  The  glandular  form 
of  endometritis  is  an  hyperplasia  of  the 
mucosa,  of  which  the  causes  act  indi- 
rectly upon  the  endometrium,  such  as 
onanism,  sexual  exccs.'ses,  psychical  in- 
fluence*, diseases  of  the  ovaries,  etc. 
The  interstitial  form  is  the  result  of 
infection  or  direct  interference  with  the 
endometrium.     The    glandular    form    is 


700 


EXDOMETEITIS.    PATHOLOGY. 


more   frequently   the   cause   of   sterility 
than  the  interstitial  variety.    Veit  (Zeit. 
f.  Geburts.  und  Gyuak.,  B.  32). 
Excessive   coitus,   masturbation,   ova- 
ritis, uterine  fibroids,  infiammation  in 
neighboring  pelvic  organs,  and  interfer- 
ence with  uterine  drainage  by  stenosis 
may  lead  to  it. 

Gonorrhoea  of  the  uterus  produces  in 
all  cases  an  inflammation  of  the  mucous 
membrane,  designated  as  an  interstitial 
endometritis  with  suppurative  catarrh, 
and  in  a  not  inconsiderable  number  of 
cases  the  chronic  course  leads  to  increase 
in  the  number  of  glands.  Wertheim 
(Centralb.  f.  Gynak.,  No.  20,  '95). 

Mycosis  of  the  cervical  canal  is  prob- 
ably a  more  frequent  cause  of  obstinate 
catarrh  than  is  generally  supposed.  Calpe 
(Centralb.  f.  Gyniik.,  No.  27,  '95). 

Endometritis  fungosa  may  sometimes 
be  found  in  virgins.  The  first  character- 
istic symptoms  appear  with  the  first 
mensti-uation.  Infection  with  micro-or- 
ganisms, masturbation,  and  traumatisms 
are  etiological  factors.  Latour  (Kevue 
Inter,  de  M6d.  et  Chir.  Prat.,  No.  IS, 
'90). 

Number  of  cases  observed  in  which 
there  was  chronic  catarrhal  inflamma- 
tion of  the  virgin  uterus,  and  such 
marked  eversion  of  the  cervical  lips  as 
to  give  the  appearance  of  an  ordinary 
puerperal  laceration  of  the  cervi.x.  In 
most  instances  the  e.xcision  of  the  hyper- 
trophic mucous  membrane  and  curetting 
of  the  endometrium  will  effect  a  cure. 
P.  F.  Mundu  (Amer.  Medico-Surg.  Bull., 
May  30,  '90). 

Underlying  a  virginal  or  senile  endo- 
metritis there  is  frequently  a  condition 
of  malnutrition,  spoken  of  in  a  general 
way  as  "lithoemia."     Matthew  D.  Mann 
(Amer.  Medico-Surg.  Bull.,  May  30,  '90). 
Chronic  septic  inflammation  may  result 
from  one  or  more  acute  attacks  or  from 
infection  by  objects  introduced  into  the 
vagina  or  uterine  cavity  whether  by  oper- 
ation,   examination,    or    improper    at- 
tempts at  medication. 

Some  eases  of  foetid  endometritis  in 
aged  women  may  be  due  to  recurrence 
of  Himplc  endoiiietritis  of  earlier  life,  or 


may  be  looked  upon  as  the  result  of  a 
necrotic  process  accompanying  the  elim- 
ination of  fibromyomata  from  the  uterus. 
It  appears  from  five  to  fourteen  years 
after  the  menopause,  and  attacks  women 
,  who  have  borne  children  rather  than 
nullipari-e.  Maurange  (La  Presse  M§d., 
Jan.  26,  '95). 

Case  of  endometritis  in  a  person  who 
was  undoubtedly  a  virgin  and  who  had 
not  been  subjected  to  previous  local  in- 
strumentation never  seen.  Howard  A. 
Kelly  (Amer.  Medico-Surg.  Bull.,  May 
30,  '96). 

Bacterial    infection    is    by    no    means 
necessary   for   the   production   of   many 
cases  of  chronic  endometritis,  although 
this  condition  may  be  the  result  of  in- 
vasion by  organisms,  especially  those  of 
sepsis  and  gonorrhoea.    Warbasse  (Amer. 
Jour.  Med.  Sci.,  Feb.,  '98). 
Pathology. — The   mucous   membrane 
of  the  cervical  cavity  presents  the  same 
changes  as  those  of  other  mucous  mem- 
branes. 

Cervical  endometritis  exhibits  anom- 
alies of  secretion  with  reddening  and 
swelling  of  mucosa.  Gradual  narrowing 
of  OS;  retention  of  secretion;  contrac- 
tion. In  consequence  of  retention,  atro- 
phy of  mucous  membrane.  Ruge  (Cen- 
tralb. f.  Gynak.,  No.  26,  '95). 

Kuge  divides  endometritis  into  the 
glandular,  interstitial,  and  mixed  varie- 
ties. The  glandular  variety  is  charac- 
terized by  an  increase  of  the  adenoid 
elements,  the  interstitial  variety  by  an 
increase  in  the  fibrous  tissue,  with  more 
or  less  destruction  of  the  glands;  in  the 
mixed  form  there  is  an  increase  of  both 
the  interstitial  and  the  glandular  struc- 
ture. H.  J.  Boldt  (New  York  Med.  Jour., 
Bee.  20,  1902). 

The  alkaline  mucous  discharge  that 
hangs  from  the  cervix,  together  with  the 
congestion  and  infiltration,  often  pro- 
duces an  exfoliation  of  the  squamous 
epithelium  of  the  vaginal  portion,  with 
reproduction  in  the  form  of  cylindrical 
epithelium.  This  condition  is  called 
simple  erosion.  The  infiltration  and 
swelling  of  the  submucous  tissues  causes 
more  or  less  of  a  rolling  out,  or  eversion, 


Fi^.2 


Fig.  3 


,^mm^.^^ 


Mi'- 

■•-  '\ 

Wii 

:r-^    r  ■   :■  ,-.    .-  ;  ^:     f    ■-■■      :,'  s 


■■■■    '       ::::^f^M^^O:-    ^ 


n    ^ 


Fig.  4 


Ficj.  .5 


,■;  .■^-'■*irvii-vx§» 


\^^" 


^- 


Comparative  Histology  of  Endometritis  (Zweifel.l 

Fiq.l.  Normal  Mucous  Membrane.    Fiq  2.Beqinning  Erosion  of  Corvix.    Fiq  3.  Glandular  Endometritis 
Fiq  4.  Acute    and   Chronic    Interstitial   Endometritis,     Fiq  S.  Chronic    Interstitial    Endometrit:s. 


ENDOMETRITIS.    PATHOLOGY. 


701 


of  the  mucous  membrane  of  the  cervical  1 
cavity,  which  is  more  pronounced  on  a 
lacerated  cervix.  More  or  less  folding  of 
the  mucous  membrane  may  give  the  ap- 
pearance of  a  papillary  or  granular  sur- 
face, which  is  called  papillary  erosion. 
Pockets  may  form  in  these  folds  and,  to- 
gether with  the  everted  cervical  glands, 
may  become  occluded,  giving  rise  to  a 
cystic  condition  called  follicular  erosion. 
These  follicles  may  become  so  numerous, 
or  one  or  two  may  become  so  large,  that 
the  normal  cervical  tissue  is  either  dis- 
placed or  replaced  by  them,  and  cystic 
degeneration  thus  results.  Sometimes 
localized  hyperplasias  are  present,  with 
projection  of  glandular  polypoid  masses. 
(See  Colored  Plate.) 

The  uterine  mucous  membrane  above 
the  internal  os  has  somewhat  different 
characteristics  from  those  of  other 
mucous  membranes  which  have  different 
functions.  Its  glands  are  simple  depres- 
sions or  epithelial  tubules  that  extend  to 
the  muscular  walls  underneath.  Instead 
of  being  imbedded  in  firm  connective  tis- 
sue as  are  the  cervical  glands,  they  are 
surrounded  at  their  inferior  extremities 
by  muscular  fibres  projecting  from  the 
muscular  walls,  which  constitute  an  ill- 
defined  muscular  structure  called  the 
muscularis  mucosa;.  In  the  interglandu- 
lar  or  intertubular  spaces  or  fluid  are 
found  delicate  connective-tissue  fibers 
and  round  or  oblong  cells  resembling 
lymph-cells. 

When  subjected  to  intense  prolonged 
congestion  an  infiltration  of  serum  takes 
place,  raising  the  epithelial  surface  and 
causing  a  proliferation  of  the  epithelial 
cells,  with  enlargement,  as  well  as  wrink- 
ling, twisting,  or  bending  of  the  glandu- 
lar tubules;  or  in  severe  cases  a  forma- 
tion of  new  depressions  or  tubules,  some 
of  which  may  become  closed  by  bending 
or  swelling  at  their  orifices. 


In  some  cases  the  epithelium  prolifer- 
ates within  the  glands,  forming  more 
than  one  layer.  Round-cell  infiltration 
and  formation  of  new  interglandular 
tissue  may  take  place,  particularly  if 
mild  septic  infection  intervene.  In  such 
cases  agglomerations  of  glands  sur- 
rounded by  a  small  amount  of  connective 
tissue  project  from  the  surface,  forming 
polypoid  masses,  which  may  spring  from 
every  part  of  the  mucous  surface. 

Histologically,  the  epitlielium  covering 
the  mucous  surface  is  composed  chiefly 
of  large,  nucleated  leucocytes;  it  is 
swelled  and  somewhat  distorted.  The 
uterine  glands  may  be  normal  in  part, 
but  the  mouths  of  the  glands  are  very 
much  swelled  ana  there  are  many  pus- 
cells  present.  In  chronic  endometritis 
the  mucous  membrane  is  highly  granular 
and  has  an  appearance  like  that  of  polypi. 
The  term  granular  endometritis  is  highly 
improper,  and  should  be  abandoned. 
Only  fortj'-nine  cases  of  endometritis 
found  in  eighteen  hundred  gyniECological 
cases  at  the  Jolins  Hopkins  Hospital. 
The  treatment  consists  in  dilating  and 
curetting  the  uterus.  Thomas  S.  CuUen 
(Med.  Record,  May  21,  '98). 

Decidual  cells  are  never  found  in  the 
stroma  of  the  endometrium  in  the  gland- 
ular  forms    of   endometritis.      Cells   re- 
sembling the  decidual  are  found  in  the 
interstitial   and   mixed   forms   of  endo- 
metritis, but  only  in  the  superficial  lay- 
ers.    These   cells   lie   at   some   distance 
from  one  another  among  the  compara- 
tively normal  cells  of  connective  tissue. 
Trtvilladaroir   (Roussky  Vratch.  Mar.  6, 
i!m4). 
The    uterine   walls   are   usually    also 
congested,  and  some  round-cell  infiltra- 
tion takes  place  about  the  blood-vessels, 
wliich,  in  time,  leads  to  the  formation 
of  adult  connective  tissue.     Contraction 
in   this   connective  tissue   may   finally 
cause  anaemia  of  the  uterine  walls  and 
more  or  less  atrophy  of  the  muscular 
fibres. 

The  mucous  membrane  is  hyperaemic, 
softened,   thickened,   and   dark   red   in 


702 


EXDOilETRITIS.    PATHOLOGY. 


color.  In  places  it  may  have  a  mottled 
appearance,  due  to  minute  extravasa- 
tions of  blood.  The  surface  is  smooth, 
sometimes  irregular,  and  is  moistened 
with  a  thin,  clear,  grayish  or  pinkish 
mucus.  The  pouting  mouths  of  the  con- 
gested and  enlarged  glands  are  -risible. 
The  uterine  walls  are  slightly  thicker 
and  the  uterine  cavity  somewhat  longer 
than  normal  (from  2  ^/^  to  3  inches  deep 
from  the  external  os  to  the  fundus). 
This  condition  is  that  of  glandular  en- 
dometritis, or  hyperplasia  of  the  endome- 
trium, and  is  seldom  the  result  of  infec- 
tion.   It  is,  as  a  rule,  chronic. 

During  the  menstrual  periods  the  con- 
gestion is  intense,  and  there  is  more  or 
less  extravasation  of  blood  in  the  inter- 
glandtilar  spaces,  and  an  extensive  ex- 
foliation of  the  epithelium. 

When  the  congestion  results  suddenly 
from  causes  acting  during  or  just  before 
the  menstrual  period,  it  is  also  intense 
and  accompanied  by  interglandular  ex- 
travasation and  blood-stasis  that  inter- 
fere with  the  menstrual  discharge,  and 
which,  if  not  relieved,  runs  into  the 
chronic  form. 

In  ac«/e  septic  endometritis  the  blood- 
vessels of  the  endometrium  are  engorged 
and  increased  in  number.  There  is  con- 
siderable exfoliation  and  proliferation  of 
the  epithelial  cells,  sometimes  to  such 
an  extent  as  to  cause  a  superficial  ne- 
crosis. The  interglandular  spaces  are 
crowded  with  round  cells,  leucocytes, 
and  cocci  which  may  extend  into  the 
muscularis  mucosae  and,  if  streptococci 
be  present,  a  short  distance  into  the  uter- 
ine walls.  Congestion,  extravasation  of 
blood,  serous  and  round-cell  infiltration 
take  place  throughout  the  uterine  tissue, 
and  a  fibrinous  exudate  may  appear  on 
the  peritoneal  surface. 

Eighteen  cases  of  infectious  diseases, 
showing  ttiat  the  blood-vceaels  of  the 
endometrium   were   inlcnnely  congested, 


particularly  the  small  veins  and  the  cap- 
illaries. Ecchymoses,  either  in  patches 
or  disseminated  all  over  the  surface  of 
the  mucous  membrane,  were  present. 
The  glandular  epithelium  was  swelled, 
the  cells  were  desquamated,  and  the 
lumina  of  the  glands  filled  with  cells, 
mucus,  and  blood-corpuscles.  The  glands 
frequently  penetrated  very  deeply  into 
the  muscular  layer,  this  being  a  charac- 
teristic sign  of  endometritis.  An  haemor- 
rhagic  endometritis  was  found  to  be  pres- 
ent in  all  of  these  cases.  Massen  (Gaz. 
de  Gyn.,  Mar.  15,  '91). 
There  is  a  more  or  less  abundant  flow 
of  pus  from  the  endometrium. 

In  chronic  septic  endometritis  round 
cells  and  leucocytes  crowd  the  inter- 
glandular spaces,  compressing  the  glands 
and  in  places  penetrating  and  destroying 
them.  After  a  time  the  formation  of 
contracting  adult  connective  tissue  com- 
presses and  obliterates  some  glands,  and 
obstructs  the  mouths  of  others,  convert- 
ing them  into  small  cysts.  The  epi- 
thelium in  the  atrophic  glands  and  on 
the  surface  also  degenerates;  so  that  in 
old  and  senile  cases  the  mucous  mem- 
brane may  be  represented  by  a  thin  layer 
of  sclerotic  connective  with  only  vestiges 
of  epithelial  structure. 

The  uterine  walls,  at  first  hyperaemic 
and  infiltrated  to  a  greater  or  less  depth 
with  serum  and  round  cells,  are  thicker 
and  softer  than  normal,  but  later,  owing 
to  the  contraction  of  the  inflammatory 
tissue,  become  hardened.  The  atrophy 
of  the  muscular  tissue  and  absorption  of 
the  serum,  as  well  as  the  senile  changes, 
may  finally  lead  to  a  diminution  in  size 
of  the  entire  organ. 

Endometritis  occurring  in  connection 
with  abortion  may  interfere  with  the 
atrophy  of  the  decidua,  and  masses  of 
decidual  cells  may  be  found  in  the  en- 
dometrium in  connection  with  the  round- 
cell  infiltration. 

In  some  cases  the  menstrual  conges- 
tion is  80  great  that  an  acute  attack  is 


ENDOMETKITIS.    PROGNOSIS.    TREATMENT. 


703 


practically  lighted  up  at  each  period. 
The  stroma-cells  are  enlarged  and  re- 
semble decidual  cells,  and  the  tissues  are 
crowded  with  leucocytes.  The  conges- 
tion is  so  great  that  there  is  an  abundant 
extravasation  of  blood  in  the  intergland- 
ular  spaces,  which  loosens  the  superficial 
portion  to  the  extent  of  causing  its  ex- 
foliation in  places  or  even  entire,  as  a 
more  or  less  complete  cast  of  the  uterine 
cavity. 

After  the  menopause  the  cervix  may 
become  stenotic,  and  the  discharges  be 
retained.  The  uterine  cavity  may  then 
become  distended,  and  the  uterine  walls 
attenuated  by  an  ofEensive  and  purulent 
fluid. 

The  menopause  does  not  e.xercise  a 
curative  influence  upon  endometritis  and 
its  resulting  leucorrhoea.  Jacobs  (Amer. 
Jour.  Med.  Sciences,  Apr.,  '94). 

The  characteristic  pathological  features 
of  acute  senile  endometritis  are  a  thick- 
ened endometrium,  the  free  surface  of 
which  is  devoid  of  its  epithelial  layer; 
increased  vascularity  with  peculiar  ar- 
rangement of  small  blood-vessels;  small 
round-celled  infiltration;  diminished 
glandular  elements;  degeneration  of  the 
coats  of  the  arteries  of  the  muscular 
layer  of  the  organ;  in  not  one  section 
examined  from  various  parts  of  the  organ 
could  there  be  found  any  increase  of  con- 
nective tissue.  L.  H.  Dunning  (Jour. 
Amer.  Med.  Assoc.,  Nov.  3,  1900). 

Prognosis. — The  prognosis  of  acute 
metritis  in  the  puerperal  state  or  after 
abortion  is  grave.  The  patient  may  die 
of  septicaemia,  or  the  disease  may  extend 
to  the  Fallopian  tubes,  ovaries,  and  peri- 
toneum, or  into  the  veins  or  lymphatics 
of  the  broad  ligament,  or  it  may  result  in 
chronic  endometritis  and  subinvolution. 

When  not  connected  with  pregnancy 
the  disease  seldom  terminates  fatally,  but 
is  apt  to  extend  to  the  adnexa  or  become 
chronic. 

Acute  cervical  metritis  mav  end  in  re- 


covery, but,  as  a  rule,  becomes  chronic. 
Chronic  cervical  metritis  may  get  well, 

but,  as  a  rule,  it  persists  for  a  long  time. 

It  can  ordinarily  be  cured  either  by  local 

treatment  or  operation. 

Chronic  corporeal  endometritis  of  the 

septic  variety  is  apt  to  get  well  if  there 

is   good   drainage   through    the   cervix. 

Without  adequate  drainage  it  becomes 

chronic  and  is  liable  to  spread   to   the 

adnexa. 

In  the  non-puerperal  uterus  the  risk 
of  the  inllammation  spreading  to  the 
tubes  is  little  save  when  the  cervical 
canal  is  obstructed  or  the  infection  gon- 
orrhoeal  in  nature.  W.  P.  Carr  (Vir- 
ginia Med.  Semimonthly,  Jan.  8,  '97). 

The  prognosis  of  foetid  endometritis  is 
favorable,  though  recurrence  may  occur 
after  curettement.  Mansange  (Arch,  de 
Tocol.  et  d'Obstet.;  Centralb.  f.  GynUk., 
No.  21,  '97). 

In  cases  of  long  standing  the  septic 
condition  can  be  removed,  but  the  endo- 
metrium and  myometrium  can  seldom  be 
restored  to  a  normal  state. 

The  sterility  is  apt  to  be  permanent. 

Chronic  glandular  endometritis  can 
generally  be  cured  by  treatment.  Mild 
or  recent  cases  may  get  well  spontane- 
ously, but  severe  cases  usually  persist  for 
a  long  time,  or  until  the  menopause. 

Treatment. — For  acute  metrilis  due  to 
suppression  of  the  menses  the  flow  should 
be  re-established  if  possible  in  the  early 
or  congestive  stage.  As  soon  as  possible 
after  the  suppression  the  patient  should 
take  a  warm  sitz-bath  (100°  F.),  and  go 
to  bed.  Hot  drinks,  hot  poultices  to  the 
abdomen  and  groins,  and  hot-water  bags 
or  bottles  to  the  feet  and  legs  should  be 
employed.  In  married  women  scarifica- 
tion of  the  cervix  may  be  used  with  bene- 
fit. The  production  of  slight  nausea  by 
means  of  tartar  emetic,  ipecac,  or  lobelia 
is  useful  as  a  sedative  to  the  congested 
pelvic  organs.  If  the  menstrual  flow  is 
re-established  by  these  means  within  a 


704 


ENDOMETRITIS.     TREATMENT. 


day  or  two,  the  patient  may  leave  the  bed 
after  the  flow  has  ceased,  but  should  lie 
down  two  or  three  hours  in  the  middle 
of  each  day,  and  take  but  little  exercise 
for  three  or  four  weeks.  At  the  time  of 
the  next  period  she  should  keep  to  the 
bed  and  repeat  the  hot  applications,  etc., 
if  the  flow  does  not  appear  on  time.  The 
bowels  should  be  kept  open  by  salines. 

If  the  menses  are  not  re-established 
within  two  or  three  days  after  their  sup- 
pression, the  patient  should  remain  in 
bed  for  a  week  or  ten  days,  apply  counter- 
irritants  over  the  iliac  and  suprapubic 
regions,  and  take  copious  hot  douches 
(115°  to  120°  F.)  two  or  three  times  daily 
in  the  recumbent  posture.  She  should 
secure  a  daily  evacuation  of  the  bowels 
and,  if  practicable,  introduce  small  cot- 
ton tampons,  saturated  with  a  10-per- 
cent, solution  of  ichthyol  in  boiled 
glycerin,  high  up  into  the  vagina  every 
other  day,  and  leave  them  for  about 
eighteen  hours.  Tonics  and  an  easily- 
digested  diet  should  be  prescribed. 

Acute    metritis    following    labor    or 
abortion  calls  for  a  thorough  evacuation 
of  the  uterus  by  the  fingers  or  curette, 
and,  if  septic  symptoms  persist,  antisep- 
tic  intra-uterine   douches  every  twelve 
hours  (Vaooo  of  corrosive  mercuric  chlo- 
ride followed  by  sterilized  water  or  1-per- 
cent, creolin)  and  vaginal  douches  of  the 
same  character  every  six  or  eight  hours. 
Treatment   of   beginning   endometritis 
by    means    of    medicated    steam    recom- 
mended.    Resorcin   at  Vm  and   varying 
in  temperature  from   104°  to  140°  F.  is 
used.     But  slight  dilatation  of  the  cer- 
vical canal  is  required,  and  accidents  are 
thus   avoided.     The  exudations   become 
coagulated  and  are  excreted  by  means 
of  contractions,  causing  a  mild  form  of 
colic.     Sordes    (.Jour,   de  MCd.   de   Bor- 
deau.K,  Sept.  1,  '9.5). 

Excellent  roBults  obtained  in  seven  out 
of  eight  cases  of  septic  endometritis 
after  labor  and  abortion  by  the  injection 
of   superheated   steam    into   the   uterine 


cavity.  The  apparatus  consists  of  a 
metal  can  with  a  spirit-lamp  and  a  ther- 
mometer which  registers  up  to  200°  C, 
some  rubber  tubing,  and  a  catheter.  The 
application  lasts  about  half  a  minute, 
and  never  over  a  full  minute.  By  means 
of  a  tap,  the  current  of  steam  can  be  in- 
terrupted while  the  catlieter  is  being 
adjusted  before  use,  lest  scalding  or 
burning  should  occur.  The  temperature 
of  the  steam  must  be  a  little  above 
boiling-point,  about  110°  C.  The  jet  of 
steam  is  followed  by  no  bad  effects  and 
gives  little  or  no  pain.  Uterine  contrac- 
tions are  actively  stimulated  and  ill- 
smelling  discharges  cease.  Steam  kills 
the  bacteria  in  the  endometrium,  and  as 
it  coagulates  albumin  all  blood-vessels 
and  lymphatics  are  sealed  up,  and  fresh 
granulations  can  develop  under  the  pro- 
tective covering.  Kahn  (Centralb.  f. 
Gyniik.,  No.  49,  '96). 

Excellent  results  obtained  from  tinct- 
ure of  iodine  in  post-partum  endometritis. 
It  acts  best  when  used  in  the  early  stages 
and  as  often  as  once  or  even  twice  daily. 
As  soon,  however,  as  the  signs  of  acute 
inflammation  subside  and  the  secretion 
diminishes,  the  remedy  should  be  ap- 
plied less  frequently.  Pains  of  varying 
character  usually  follow  this  mode  of 
treatment.  The  method  of  application  is 
as  follows:  The  patient  lies  on  her  back, 
and  a  speculum  is  introduced  into  the 
vagina.  If  the  cervix  is  blocked  with 
mucus,  the  os  is  drawn  down  with  a 
volsella,  the  portio  vaginalis  is  irrigated, 
and  the  parts  dried  with  aseptic  cotton- 
wool; the  canal  is  then  swabbed  with 
the  pure  tincture  of  iodine.  In  cases  in 
which  the  corpus  uteri  is  also  involved 
the  remedy  is  applied  in  the  same  way 
as  to  the  cervix.  A.  Solowjev  (Wratch, 
No.  12,  '97). 

Bromine-vapor  most  satisfactory  agent 
in  the  treatment  of  endometritis.  It 
is  introduced  into  the  uterine  cavity 
through  a  double-current  catheter  at- 
tached to  an  atomizer,  dirriises  rapidly, 
and  exerts  a  remarkable  curative  action 
in  cases  of  acute  ondomotritis  and  sal- 
pingitis. Nitot  (LaGynOcologie,Oet.,  '97). 

A  steam-jet  at  a  temperature  of  100° 
C.  in  endometritis  and  in  various  septic 
and  chronic  inllnmmatory  conditions  ad- 


ENDOMETRITIS.    TREATMENT. 


705 


vocated  after  use  in  thirty-one  cases. 
Used  carelessly,  there  is  some  danger  of 
obliterating  the  lumen,  but  with  ordi- 
nary precautions  it  is  perfectly  safe. 
Johnson  (Boston  Med.  and  Surg.  Jour., 
Mar.  16,  1900). 

When  the  attack  follows  an  operation, 
an  ice-bag  should  be  kept  on  the  lower 
abdomen  for  twenty-four  or  thirty-six 
hours,  the  infected  surfaces  be  thor- 
oughly disinfected  by  a  strong  antiseptic, 
and  one  of  the  above-mentioned  antisep- 
tic douches  be  used  either  to  the  endome- 
trium or  vagina  as  required. 

As  the  inflammation  subsides,  hot 
douches,  laxatives,  tonics,  rest  in  bed, 
etc.,  are  indicated. 

In  chronic  uterine  inflammation  all 
causes  of  the  diseases  and  all  conditions 
that  perpetuate  it  should  receive  atten- 
tion. 

Septic  forms  require  active  antiseptic 
treatment.  In  those  forms  of  chronic 
endometritis  in  which  hsemorrhage  is  a 
prominent  symptom,  especially  where  an 
exact  diafjnosis  is  required,  the  curette 
is  advisable,  ^^'^lere  leucorrhcea  is  the 
chief  characteristic,  or  where  the  curette 
has  failed,  a  powerful  caustic  is  re- 
quired; and,  of  those  which  have  proved 
cfTeetual,  chloride  of  zinc  is  perhaps  the 
most  certain.  But  we  may  liope  in  the 
near  future  to  see  it  replaced  by  some 
better  method,  possibly  by  formalin 
and  atmocausis.  Symly  (Glasgow  Med. 
Jour.,  May,  1902). 

In  puei-peral  septic  endometritis  the 
insertion  into  the  uterine  cavity  of 
tampons  of  iodoform  gauze  soaked  in 
1  to  8  glycerin  ichthyol  and  thickly 
powdered  with  naphthalin  gives  prompt 
and  satisfactory  results.  Poliansky 
Prakt.  Vratch,  May  31,  1903). 

Displacements  should  as  far  as  possible 
be  corrected,  stenosis  relieved,  and  pelvic 
inflammatory  conditions  and  tumors  be 
treated  or  removed. 

Most  marvelous  results  acliieved  in 
htemorrhage  depending  upon  chronic  en- 
dometritis with  chronic  peritonitis,  by 
the  hypodermic  use  of  a  solution  con- 


taining 1 '/,  drachms  each  of  crystallized 
phosphate  and  sulphate  of  soda  dissolved 
in  4  ounces  of  distilled  water.  Erom  1 
to  1  Vi  drachms  of  this  solution  is  to  be 
injected  into  the  buttock  or  thigh  twice 
a  week.  The  solution  must  be  made 
fresh  and  filtered  each  time.  ChCron 
(Jour.  Amer.  Med.  Assoc.,  Apr.  28,  '88). 
Application  of  an  ethereal  solution  of 
iodoform  to  the  cervical  canal  recom- 
mended in  obstinate  cases.  Dolfiris  (Bull. 
Gen.  de  Ther.,  No.  11,  '97). 
The  patient  should  remain  in  bed  dur- 
ing a  portion  or  all  of  the  menstrual 
period,  and  take  more  than  ordinary  care 
of  herself  after  abortions  or  confinements. 
WTien  menstruation  is  imminent  or 
present,  treatment  should  be  withheld. 
An  exception  to  this  rule  would  obtain 
should  the  flow  be  very  profuse  or  pro- 
tracted. In  the  presence  of  an  acute 
inflammatory  process  intra-uterine  treat- 
ment should  be  withheld.  In  malignant 
disease  of  the  cervix,  the  possibility  of 
a  severe  hcemorrliage  attending  local 
treatment  of  whatever  character  must 
be  anticipated  and  provided  for.  In  all 
cases  the  risk  of  inflammatory  reaction 
in  pelvic  structures  remote  from  the  cer- 
vix must  be  taken  into  consideration. 
Currier  (Trans.  Med.  Soc.  State  of  N.  Y., 
Feb.,  '90). 

Stress  laid  on  the  complications  which 
endometritis  may  set  up  in  a  patient 
who  becomes  pregnant.  The  acute  form 
is  generally  secondary.  Chronic  endo- 
metritis attacks  the  decidua  vera.  The 
cause  of  endometritis  is  usually  gonor- 
rhcea.  Syphilitic  endometritis  is  prob- 
able. Endometritis  cannot  be  treated  as 
long  as  the  pregnancy  lasts.  Only  when 
syphilis  is  suspected  can  benefit  be  de- 
rived from  drugs.  After  delivery  or 
abortion  the  endometritis  can  be  treated 
by  the  free  use  of  the  curette.  The  in- 
creased vascularity  of  the  decidua  vera 
explains  the  frequency  of  hasmorrhages 
during  pregnancy.  The  decidua  rcflexa 
is  rarely  attacked:  hence  the  placenta 
is  usually  found  healthy,  and  the  child 
may  be  delivered  alive.  Tarnicr  (Jour, 
des  Sagcs-fcmmcs,  .Tan.  1,  '01). 
Chronic  glandular  endometritis,  alone 
or  in  connection  with  chronic  septic  or 


706 


ENDOMETRITIS.    TREATME^'T. 


interstitial  endometritis,  and  all  menor- 
rhagic  cases  uncomplicated  by  pelvic 
peritonitis  should  be  curetted. 

Dilatation,  curetting,  irrigation,  and 
draining  recommended  as  the  best  and 
most  rapid  method  of  obtaining  a  cure. 
Waldo  (X.  Y.  Med.  Jour.,  Feb.  13,  '92) ; 
Baldy  (Med.  and  Surg.  Rep.,  Mar.  12, 
"92) ;  Xoble  (Annals  of  Gynsecology  and 
Psediatry,  June,  '92) ;  Garrigues  (Times 
and  Register,  Apr.  30,  '92) ;  Gossmann 
(Muncliener  med.  Woch.,  May  31,  '92) ; 
Thielhaber  (Miinchener  med.  Woch.,  June 
28,  '92) ;  Goffe  (Virginia  Med.  Monthly, 
Sept.,  "92). 

Sixty-five  cases  of  endometritis  fun- 
gosa  treated  by  curetting;  92.2  per  cent, 
completely  cured;  13.8  per  cent,  much 
improved.  Should  be  performed  with 
patients  in  Sims's  position.  Hans  Vogel- 
baeh    (Inaugural   Dissertation,  '9-1). 

The  most  thorough  results  are  ob- 
tained when  both  the  curette  and  the 
sharp  spoon  are  used,  especially  the 
smallest-sized  instruments,  which  can  be 
inserted  into  the  cornua  of  the  uterus 
and  between  the  rugse.  Where  there  is 
marked  glandular  hyperplasia,  early  re- 
currence is  apt  to  follow  the  most  vig- 
orous scraping  unless  the  raw  surface 
is  thoroughly  cauterized  at  once.  R. 
Werth  (Archiv  f.  Gynilk.,  B.  49,  H.  3, 
'95). 

In  297  eases  treatment  consisted  of 
dilatation  and  curettage  of  the  uterine 
cavity,  followed  by  thorough  application 
to  the  endometrium  of  50-per-cont.  solu- 
tion of  chloride  of  zinc  in  the  worst 
cases,  and  of  a  solution  of  iodized  phenol 
in  milder  cases.  A  sterilized  drain  was 
tlien  inserted  tlirougli  the  internal  os, 
the  patient  put  to  bed,  and  all  precau- 
tions taken  against  inflaiiiniatory  reac- 
tion. A  repetition  of  the  cauterization 
with  milder  solution,  if  thought  best, 
usually  resulted  in  a  permanent  cure  in 
the  course  of  two  or  three  weeks.  There 
were  197  cures  and  94  cases  of  improve- 
ment out  of  297  operation.^,  only  C  being 
mentioned  as  discharged  unimproved. 
The  best  hope  for  a  permanent  cure  of 
chronic  endometritis  would  result  from 
impregnation  and  normal  delivery.  Paul 
F.  Munde  ("Report  of  Gyntccological 
Service  at  Mount  Sinai  Hospital,"  '95). 


In  acute  catarrhal  endometritis  elec- 
tricity is  an  effective  remedy,  faradiza- 
tion and  the  negative  pole  of  the  gal- 
vanic current  fulfilling  the  requirements 
of  local  treatment.  In  chronic  catarrhal 
endometritis  the  positive  pole  of  the  gal- 
vanic current  and  zinc  electrolysis,  com- 
bined with  faradization,  are  also  effect- 
ive. Acute  septic  or  speeifie  endome- 
tritis demands  gentle  dilatation  and 
thorough  irrigation  with  antiseptic  solu- 
tions. In  chronic  endometritis  resulting 
from  septic  or  specific  infection,  cu- 
rettage, gauze  drainage,  and  subse- 
quently irrigation.  Senile  endometritis 
can  best  be  overcome  by  dilatation  and 
drainage  brouglit  about  by  means  of  the 
negative  pole  of  the  galvanic  current, 
and,  when  necessary,  irrigation  of  the 
cavity  with  a  saturated  solution  of  boric 
acid  or  Thiersch's  solution.  A.  H.  Goelet 
(Amer.  Jour,  of  Obstet.,  Sept.,  '95). 

Curettage   has   proved   disappointing; 
if  the  infection  of  the  mucous  membrane 
is  recent,  curetting  is  very  liable  to  open 
up  new  channels  of  infection,  carrying 
the  inflammation  to  deeper  parts;  if,  on 
the  contrary,  the  infection  is  an  old  one. 
the  deepest  portions  of  the  endometrium 
have     probably     become     affected,     and 
those  laj'ers  curettage  could  not  remove 
without    destroying    the    entire    mem- 
brane.    In  eases  of  septic  and  of  acute 
puerperal  infection,  curettage  is,  there- 
fore,   useful    only    for    the    purpose    of 
removing  foreign  material,  retained  and 
adherent    (Kbris,    etc.      H.    T.    Byford 
(Wisconsin   Med.   Recorder,   iii.  No.   11, 
1900). 
When  the  curette  is  employed  due  care 
should  be  exercised.     Eough  manipula- 
tion and  undue  pressure  upon  the  uter- 
ine surfaces  have  been  followed  by  un- 
toward   results.      Curettage    should    be 
avoided  when  there  is  tenderness  in  the 
tissues  beside  the  uterus. 

Temporary  uterine  paralysis  occasion- 
ally occurs  during  the  operation  of  cu- 
retting under  chloroform  mircoaia,  which 
might  lead  one  to  think  that  ho  had 
perforated  the  uterine  wall  and  was  mov- 
ing the  curette  freely  in  the  peritoneal 
cavity,  were  it  not  for  the  absence  of 
shock,  as  manifested  by  the  normal  pulse, 


ENDOMETRITIS.    TREATMENT. 


ror 


respiration,  and  appearance  of  the  pa- 
tient.   Geyl  (Arch.  f.  GynUk.,  II.  3,  '88). 

Four  eases  noted  where  death  has  oc- 
curred from  septic  peritonitis  after  cu- 
retting. Reeves  Jackson  (Annals  of 
Gynec.,  Apr.,  '88). 

Case  of  death  reported  resulting  from 
an  intrauterine  injection  of  perchloride 
of  iron.  The  patient  was  curetted  for 
endometritis,  and,  owing  to  the  bleeding, 
the  following  day  iron  was  carefully  in- 
jected drop  by  drop.  She  died  two  hours 
later.  At  the  post-mortem  clots  were 
found  in  the  uterus  and  thrombi  in  the 
iliac  veins.  Pletzer  (Provincial  Med. 
Jour.,  Aug.,  '92). 

The  greatest  danger  of  the  curette 
does  not  lie  in  perforating  the  walls  ot 
the  uterus,  but  in  salpingitis,  the  ex- 
citation of  peristaltic  movements,  and 
the  forcing  of  material  into  the  peri- 
toneum. The  worst  procedure  that  can 
be  imagined  in  this  connection  is  to  fol- 
low curetting  by  injection.  Landau 
(Med.  Press  and  Circ,  Dec.  5,  '94). 

Case  in  which  perforation  with  curette 
ended  in  death.  Ratlay  (These  de  Paris, 
'95). 

[Uterus  punctured  in  a  number  of 
cases  and  in  none  of  them  have  any  ab- 
normal symptoms  resulted.  E.  E.  Mont- 
gomery, Assoc.  Kd.,  Annual,  '9G.] 

Regeneration  of  endometrium  after 
curetting  varies  widely,  according  to 
manner  in  which  operation  performed. 
Where  tliere  is  marked  glandular  hyper- 
plasia, early  recuiTence  apt  to  follow 
most  vigorous  scraping  unless  raw  sur- 
face cauterized  at  once.  When  liquor 
ferri  applied  after  curetting,  regenera- 
tion of  epithelium  delayed.  R.  Werth 
(Archiv  f.  Gyniik.,  B.  49,  H.  3,  '95). 

Fifteen  days  a  minimum  limit  for  the 
uterine  mucosa  to  reproduce  itself  so  as 
to  be  physiologically  active  after  cu- 
retting. Bossi  (Gaz.  degli  Osp.,  Feb.  2, 
'95). 

Exfoliative  endometritis  and  polypoid 
endometritis  may  require  more  than  one 
curettage. 

In  a  large  proportion  of  cases  the  cer- 
vical canal  is  small  or  bent,  and  must  be 
kept  diluted  for  several  weeks  subse- 
quently  to   promote   uterine    drainage. 


Introduction  of  a  gauze  pad  or  drain 
into   the    non-puerperal   uterus   for   the 
purpose  only  of  drainage  is  unnecessary 
and  possibly  open  to  objection.     While 
the   presence   of   a   pad   of  gauze   in   a 
flabby,  septic  uterus  after  curetting  may 
produce  contraction  of  that  organ,  still 
it  acts  as  an  obstacle  to  the  escape  of 
septic    discharges.     H.    C.    Coe    (Amer. 
Gyntec.  and  Obstet.  Jour.,  June,  '95). 
In  others  it  is  necessary  to  use  strong 
astringents  and  antiseptics  to  the  endo- 
metrium, to  counteract  the  tendency  to 
a  recurrence  of  the  hyperplasia  or  the 
sepsis. 

The  hot  vaginal  douche  twice  daily 
acts  beneficially  as  a  sedative  to  the  pel- 
vic circulation,  and  aids  in  keeping  the 
vagina  clean. 

Local  treatment  may  be  commenced 
in  two  or  three  weeks  after  the  operation. 
If  the  cervix  is  small  or  bent,  a  round 
dilator,  or  male  urethral  sound  Xo.  13 
to  No.  15,  should  be  passed  through  the 
internal  os  once  or  twice  a  week.  In 
order  to  avoid  infection,  the  patient 
should  take  a  large  hot  vaginal  douche 
shortly  before  the  treatment,  and  the 
gynagcologist;.  should  wipe  out  and  dis- 
infect the  vaginal  fornices  and  cervix 
through  the  speculum  before  intro- 
ducing the  disinfected  sound. 

After  the  sound  is  withdrawn  a  50-per- 
cent, solution  of  ichthyol  in  glycerin 
may  be  applied  to  the  endometrium,  or, 
if  the  case  has  been  an  ha3morrhagic  one, 
pure  lysol  or  carbolic  acid,  or  a  20-per- 
cent, solution  of  chloride  of  zinc,  every 
ten  days  to  two  weeks. 

Carbolic  acid  most  efficient  and  safest 
application.  Does  not  bum  deeply 
enoiigh  to  destroy  subnnieous  tissue. 
Not  good  practice  to  make  traction  upon 
organ  and  pack  it  every  other  day.  A. 
P.  Dudley  (Amer.  Jour.  Obstet.,  Sept., 
'05). 

Treatment  by  chloride  of  zinc  given  up 
because  of  the  tendency  of  this  ngcnt  to 
produce  cicatrization  of  the  surface.  A. 
Jacobi  (Med.  Record,  Oct.  19,  '95). 


708 


ENDOMETRITIS.    TREATMENT. 


More  general  use  of  nitrate  of  silver  i 
advocated  in  the  treatment  of  endometri- 
tis. The  application  of  the  nitrate  of 
silver  should  be  made  carefully  and 
thoroughly,  and  to  do  this  it  is  abso- 
lutely necessary  that  all  unhealthy  se- 
cretions should  be  removed  previously 
from  the  interior  of  the  uterus,  and  the 
latter  be  left  clean  and  dry.  For  mild 
cases  and  those  seen  early  5-  or  10-grain 
solution  of  nitrate  of  silver  used,  but 
the  more  chronic  cases  require  much 
stronger  solutions  or  even  a  light  touch- 
ing with  the  solid  stick.  William  H. 
Eobb  (N.  Y.  Med.  Jour.,  Dec.  5,  '96). 

Applications  of  nitrate  of  silver  are 
followed  immediately  by  an  apparent  im- 
provement or  cure;  but  further  observa- 
tion will  show  that  the  treatment  has 
left  an  atrophic,  non-secreting,  and  irri- 
table endometrium.  There  is  no  such 
objection  to  the  use  of  the  curette.  L. 
J.  Brooks  (X.  Y.  Med.  Jour.,  Dec.  5, '96). 
Three-per-cent.  solution  of  lactic  acid 
injected  into  the  vagina  overcomes  the 
odor  that  may  be  present  in  cases  of  leu- 
corrhoca,  changes  the  color  of  the  dis- 
charge, and  may  be  used  without  danger 
in  ambulatory  practice  and  in  cases  of 
salpingo-oijphoritis.  In  certain  cases  the 
intra-uterine  employment  of  a  stronger 
solution  may  be  substituted  for  the  use 
of  the  curette.  Ilkewitsch  (Centralb.  f. 
GynUk.;  Texas  Med.  News,  Dec,  '97). 

Naphthalin  gives  excellent  results  in 
cases  in  which  there  is  no  general  septi- 
caemia. After  drying  the  endometrium 
with  dry  tampons,  or  curetting  in  re- 
tained placenta,  a  long  strip  of  iodoform 
gauze  (3  per  cent.)  is  dipped  into 
ichthyol-glycerin  (1  to  8),  squeezed  out, 
and  powdered  abundantly  with  finely- 
powdered  naplitlialin.  This  strip  is  then 
used  to  tampon  the  uterus,  leaving  the 
tampon  in  position  for  from  six  to  twelve 
hours.  The  temperature  usually  falls  to 
normal  two  or  three  hours  after  remov- 
ing the  tampon;  the  discliarge  loses  its 
fijetidity  and  recovery  is  inaugurated.  If 
tliia  docs  not  occur,  a  second  tampon 
should  be  inserted  twelve  hours  after  the 
removal  of  the  first.  Kirzner  (Med. 
News,  July  28,  1900). 

Sircdey's  method,  viz.,  the  injection  of 
a  12  to  1000  solution  of  picric  acid  into 


the  uterine  cavity  by  means  of  Braun's 
syi-inge  used  in  21  cases.  The  solution 
is  prepared  with  hot  water,  allowed  to 
cool,  and  decanted.  It  may  be  kept 
sterile  for  an  indefinite  time.  The  cerv- 
ical canal  is  disinfected  with  cotton  im- 
pregnated with  iodoform-ether,  and  the 
syringe  is  introduced  into  the  cen'i.'c, 
and~  about  2  cubic  centimeters  injected 
into  the  uterine  carity.  The  vagina  is 
tamponed  with  iodoform  gauze,  tlie  plug 
being  worn  till  the  next  day.  The  va- 
gina is  washed  daily  with  a  hot  solu- 
tion of  potassium  permanganate.  The 
writer  also  disinfected  the  external  gen- 
itals and  irrigated  the  vagina  before  the 
introduction  of  the  speculum.  The  cases 
were  thus  treated  until  the  gonoeocci 
disappeared.  Picric  acid  proved  very 
efficient  and  non-toxic  and  showed  a 
marked  antibacterial  action  against 
gonoeocci.  The  injections  far  from  be- 
ing caustic,  were  analgesic.  Serra 
(Eiforma  Medica,  June  24,  1903). 

When  there  is  tenderness  or  irritation 
in  the  tissues  beside  the  uterus,  curettage 
and  intra-uterine  medication  are  liable 
to  do  more  harm  than  good.  In  such 
cases  a  copious  hot  vaginal  douche  (120° 
F.)  should  be  taken  at  or  near  the  noon 
hour,  followed  immediately  by  two  hours 
of  rest  in  the  recumbent  position,  and 
another  douche  at  bed-time  followed  by 
the  introduction  into  the  vaginal  vault 
of  a  tampon  saturated  with  a  10-per-cent. 
solution  of  ichthyol  in  glycerin.  The 
tampon  is  removed  when  the  noonday 
douche  is  taken. 

Laxatives,  tonics,  massage,  regulated 
out-of-door  exercise,  and  restriction  of 
coitus  are  useful  adjuvants. 

Endometritis  with  stenosis  and  py- 
omctra  (so-called  senile  endometritis) 
should  be  treated  on  the  same  principles 
as  any  pus-cavity,  viz.:  dilatation  of  the 
cervix  for  drainage,  and  the  washing  out 
of  the  uterus  with  antiseptic  solutions 
once  or  twice  daily. 

Henry  T.  Byfoud, 

Chicago. 


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